Team Up! Team-based primary and community care in action

In this special episode of TeamUP!, Morgan and Sarah host a roundtable discussion with friends of the Innovation Support Unit to talk about the past, present, and future of Primary Care change in British Columbia.The guests are both optimistic for the future and a bit sad as context of the episode’s conversation: the ISU, a unit that began eight years ago to strengthen and support Team-Based Primary Care in British Columbia, is wrapping up its core work with the BC government.Throughout the episode, guests Angela Wignall, Valerie St. John, Christie Newton, Carolyn Canfield, and Andrew Earnshaw, discuss highlights of BC’s primary care strategy, new compensation models, relationship building and team development, collaboration challenges, and foundational needs.This will be the last planned episode for TeamUP! Sarah and Morgan are not yet sure where they will turn there podcasting eye to next, but they do not want their microphones to go to waste, if there is an audience wanting to hear from them.Please enjoy this episode, and thank you for being a part of the TeamUP! community!

Wrapping Up Season 7: Reflections and Future DirectionsIn this final episode of Season 7 of TeamUP! Sarah and Morgan wrap up the season integrating nurses into primary care practices.They discuss the value of a team-based approach, their learnings about nursing roles, and how proper clinical policies and scope maximization can enhance care delivery. They address their take aways from the season like nursing diagnoses, the importance of written policy documents, and the benefits of ongoing team collaboration for clinician retention.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.And thanks to the whole ISU team and all the nurses we asked questions of in the hallways and at clinic to help with this season.

An Ask Us Anything episode! Producer Michael makes a rare appearance on the podcast where he brings your questions to Sarah and Morgan.They discuss key topics such as nurse role in primary care health promotion, disease prevention, and care coordination, highlighting the impact of nurses on patient care quality. The episode revisits topics discussed in previous episodes to drive their point home further, such as the differences between LPNs and RNs, the benefits of team-based care, and effective strategies for integrating nurses into family practices. There is an emphasis on support systems for new nurses, and the hosts provide resources you can access in the show notes below.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.Links and Resources=============TeamUP! Season 7 Episode 3Diving into the differences between Licensed Practical Nurses and Registered Nurses within primary care settings.TeamUP! Season 7 Episode 4Learning about the complexities of being an employer of a primary care nurse within smaller private clinics.TeamUP! Season 7 Episode 12How nurses can facilitate care coordination in primary care to support complex patients.Family Practice Services Committee ResourcesProvides new supports for integrating a nurse into family practice, including links to the Nurse in Practice program, along with webinars, events, and a link to the Nurse CompassPractice Support CoachesTools provided by FPSC in collaboration with the Division of Family Practice to support physicians and teams to help identify gaps, reduce overlap and redundancies, and identify quality improvements within practice.

In this special episode of TeamUP!, Morgan and Sarah explore a nurse’s transition from acute care to primary care with seasoned nurses Diana and Nikki. They’re asked what questions they have as nurses curious about entering primary care.Diana and Nikki ask about the skills required, job expectations, and specialty training necessary for primary care, as well as the importance of team dynamics and long-term patient relationships. The hosts try to answer each question while providing resources for further learning. The discussion underscores the proactive role of primary care nurses in preventing chronic conditions and highlights a nurse’s ability to carve out their preferred role within healthcare.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.Links and Resources===============PCN Jobs BCThis website provides a list of currently available jobs for healthcare professionals across the numerous Primary Care Networks of BC. Use the filter on the left to select your profession among other qualifiers.BC Health Authority WebsitesNavigate to the careers section within a Health Authority’s website and search “primary care nurse” to show results for all openings in primary care.Fraser HealthInterior HealthIsland HealthNorthern HealthVancouver Coastal Health

Episode 13 is a teamBIT that focuses on how nurses can support frail patients with complex needs through home visits and virtual touchpoints.Morgan emphasizes the benefits of nurses assessing primary care needs in an environment that patients feel most comfortable in: their home. Morgan suggests a good starting place is with patients that are not yet currently receiving home care. Another approach nurses can use is virtual touch points for more frequent communication, offering a more accessible and personalized approach to help support patients who need more care. The episode concludes with our host exploring the advantages of involving nurses in coordinating care, leveraging their functional assessment capabilities, and integrating their work with broader clinical teams.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.Links and Resources===============**https://www.aafp.org/pubs/afp/issues/1999/1001/p1481.html**This article, published in 1999, introduces the acronym “INHOMESSS” as a mnemonic that provides framework for the evaluation of a patient’s functional status and home environment.**Nurse Home Visit Guidelines: Australian Medicare Local Alliance**A guideline written for primary care nurses working in home care. This guideline provides information on the potential risks associated with entering an unknown setting and how to minimize these risks to nurses.

In this teamBIT episode, Morgan discusses how nurses can facilitate care coordination in primary care to support complex patients.Care coordination is less intensive than case management and involves assessing patient needs, connecting with community supports, and maintaining ongoing patient relationships. Morgan describes how, in care coordination, the role of nurses in optimizing care plans is emphasized, especially for frail or complex care patients. Benefits include reducing avoidable crises and ER visits, enhancing patient and family support, and helping patients remain at home longer.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.

In episode 11 of TeamUP!, Morgan and Sarah explore the significant role of nurses in aiding patients with mental health needs, particularly mood disorders, in primary care settings.The hosts discuss how common anxiety and depression are, and how nurses' skills in connecting with patients are vital in providing comprehensive care. The conversation covers the different scopes of practice for Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), and how these professionals assess and support patients with stable and unstable mental health conditions. Featuring key quotes and anecdotes from nurses in the field, the hosts look into the importance of team support, debriefing after stressful events, and the need for escalation pathways when patients require care beyond a nurse's scope of practice.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.Links and Resources===============TeamUP! Season 7 Episode 2: Nurses as a Profession — How nurses augment primary care

In this episode, Morgan and Sarah discuss how nurses can provide diabetes management in team-based primary care.Kacey, who is a certified diabetes education nurse, describes ways to introduce a nurse to diabetes management in a clinic. Morgan and Sarah also share insights into how nurses can provide patient education, streamline follow-ups, and emphasize foot care to prevent complications. The episode highlights practical tips and considerations for primary care teams to optimize diabetes care and coordinating with external diabetes education centres when possible.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.

In episode 9 of TeamUP!, the focus is on exploring the integral role nurses play in medication management within primary care teams.We will hear interview clips from Kacey, a registered nurse, who explains the responsibilities nurses hold, including taking comprehensive medical histories, assessing medication impacts, advocating for patients, and educating them about their medications. The discussion highlights the value nurses add during transitions of care and their ability to address sensitive topics, such as financial challenges, which may affect medication adherence. Nurses build patient trust, provide follow-up education, and work collaboratively within the team to enhance patient care.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.

In episode eight of TeamUP!, we learn about the benefits of shared visits with a primary care provider and a nurse.Morgan and Sarah discuss how these shared visits can enhance team capacity, improve care for complex illnesses, foster team building, and create immediate capacity in the moment. With insights from nurses, the episode highlights the importance of synchronized care plans, trust-building, and efficient multitasking, all while encouraging you to incorporate a shared visit in your practice to fully understand the benefits.Special Thanks============Throughout this season you’ll hear from several amazing nurses:Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.