Archive for the ‘Consumer health’ category

Advancing primary care in BC

June 12, 2011

Why is primary care so important?

“Primary care is the first point of contact a person has with the health system – the point where people receive care for most of their everyday health needs. Primary care is the first point of contact a person has with the health system – the point where people receive care for most of their everyday health needs. Primary care is typically provided by family physicians, and by nurses, dietitians, mental health professionals, pharmacists, therapists, and others” (What is primary care?)

Divisions of Family Practice

Under the auspices of the General Practice Service Committee, the Divisions of Family Practice was designed to both improve patient care and address family doctors’  influence on health care and professional satisfaction.  Family doctors in a community organize themselves into a non-profit to work towards common health care goals. They are able to receive funding towards their initiatives.

I learned about this initiative when I listened to a presentation made to seniors by the White Rock South Surrey Division.  One of the first of three to be established in BC, this division seeks to improve:

  • population health
  • the patient/provider experience
  • system sustainability

I was impressed that this division of 73 members has 3 staff members. Their programs promote enhanced hospital care, local citizens’ access to a family doctor (through the attachment initiative), recruitment of additional doctors to ease the shortage and continuing education programs for doctors.

Their key initiative is the Primary Care Access Clinic which supports unattached patients (lacking a family doctor) who require care upon discharge from Peace Arch Hospital. The clinic is staffed by a multidisciplinary team which includes nurse practitioners, mental health care staff and social workers and home health workers who can refer patients to needed services and monitor complex cases.

When I mentioned this interesting model to a pharmacist colleague, he had an interesting comment. He said that progressive practices will usually recognize the need to have nurse practioners, social workers…but for some reason, they don’t seem to see the need for a pharmacist. This is partly because pharmacists are often perceived as retail, business rather than clinical specialists. In addition, the physician-pharmacist interactions tend to be negative because pharmacists will usually only call physicians with bad news – that they made a mistake.

With 24 divisions, the Divisions of Family Practice model seems to be really taking off and advancing primary care. Their progressive and patient-centric approach is extremely important and they can be important allies in promoting health literacy and other key but often-neglected patient oriented interventions. However, is my colleague right – that they are failing to include pharmacists in their care teams? What are pharmacists doing to improve their interactions with and perceptions by physicians?


Patients Voices Network

April 28, 2011

Earlier this year, I had the privilege of attending a Patients Voices Network (PVN) training session. PVN is a program that recruits, trains and supports patients and their families to participate in primary health care changes.  For an interesting and informative overview about their work, see the video below which is also on their website.

PVN provides impressive opportunities for consumer participation:

  • An online community or virtual network of patients that register to provide input through response to surveys
  • Activated network of trained patients who can be involved at three levels:
    • Shaping the system: participating in focus groups, patient advisory committees and panel discussions; patient journey mapping
    • Community Activation: working in patients’ local communities to improve primary health care
    • Peer to Peer Coaching: supporting and motivating individuals to achieve healthy living goals.

One point that stood out for me was the positive approach that was emphasized by PVN. Patients’  may first be compelled to become activated members of PVN due to negative experiences with the healthcare system. While their frustration is understandable, it is important that theyare motivated by a desire to provide constructive feedback rather than hostile criticism.

Another highlight of the workshop was listening to Johanna Trimble speak about her involvement with PVN and what she has learned along the way. She had many positive experiences to relate but also cautioned participants to be balanced and acknowledge their limitations ie. not to volunteer for each and every opportunity.  Johanna, a steering committee member, has spoken at international conferences about her experience with the health care system and her presentation Is Your Mom on Drugs? – Find out what to do about it” is most compelling.

Seniors take charge of their health

January 13, 2011

Seniors taking an active role in their health

Health Watch program in Burnaby, British Columbia struck me as a really unique program for promoting wellness among seniors. This calendar outlines some of their weekly activities.  Healthwatch along with three other programs  is part of the Burnaby Partners in Seniors Wellness. It is an excellent model of what can be done when seniors come together and are supported to take charge of their own health.

  • The group is run by a volunteer board which plans and manages its activities. They request for funding from the Fraser Health Authority and have to report back on their activities.
  • The funding is used to hire a coordinator who is shared by two programs.
  • Retired health care workers have been recruited as volunteers to conduct screenings, monitor blood pressure and pulse etc.
  • The group has secured permission to collect and maintain the health records of the participants. Volunteers fill out a medical card with vital information and give participants a wallet card. Weight and blood pressure are recorded each visit and an uptodate record of medications is maintained.
  • Trained volunteers offer massage, conduct chair exercises
  • Speakers are regularly invited to speak on various topics of interest to seniors such as our medication safety session.
  • The seniors also enjoy socializing with their peers
  • Partnering with local pharmacists t0 run a clinic  where seniors can bring in their drugs and have the pharmacist “critique” them. One of the seniors brought 21 different medications.
  • Encourage their members to maintain an uptodate medication list.

Image credit: Used under creative common license Pocmont Resort and Conference Centre

Homeless shouldn’t mean hard-to-reach

January 25, 2010

Mary-Doug Wright, a health research specialist recently drew my attention to an article reporting that the San Francisco Main Library hired a social worker to work with the homeless, with amazing results. The psychiatric social worker, hired through a partnership with the San Francisco Department of Public Health,  has directed more than 150 homeless people into social services and trained some as library employees –  “health and safety associates” who monitor the facilities and distribute information to the patrons who need help.

It was an interesting coincidence that around the same time, I participated in a service fair organized by the Under One Umbrella Society to provide information and services to homeless/street-involved people in East Vancouver. The participating exhibitors included government agencies,  service delivery non-profits and advocacy groups. The fair offered:

  • physical provisions such as food, warm clothing and toiletries
  • health information and services: street nurses were giving flu shots
  • personal services such as: massages, foot care, pet care, hair cuts and bike repair
  • information on shelters, housing, social assistance, employment services and community voicemail services for people in crisis and transition
  • workshops on topics such as safety, employment and services


  • It was valuable to inform the fair attendees about the provincial prescription drug plan and how to ensure that they were registered. We found that most people who are homeless or at risk are on social assistance and depend on social workers to advocate for them. They are often unaware of the full range of benefits available to them and may lack the efficacy to demand information from a fragmented system. It is often the system that fails them.
  • As the San Francisco library’s initiative above demonstrates, the library is an integral part of the community and can play a crucial role not only in providing the more traditional information services but in responding to the homeless’ needs in practical ways. The local library branch was not represented among the exhibitors. One participant asked me where the library booth was because they were present during the last fair, a clear indication they were missed. As libraries are at the core of information provision and referral to community services, they must make every effort to be present at events like these.
  • As would be expected, there is a high demand for probono dental treatment and scant information about such services. This is certainly an information gap that needs to be addressed by social services workers and librarians.
  • In addition to meeting the information needs of the attendees, it was highly valuable for us to connecting with other service providers. Partnering with outreach workers is an important way to disseminate important information to this group.
  • Judging from the popularity of the fair (held in 2007 and 2009), this kind of event is obviously helpful in connecting with this population and responding to their immediate needs. It is however important that these one-off initiatives are supplemented by a systemic strategy to address the complex problem of homelessness. While shelters seem to be a logical approach to addressing homelessness, their underlying model is often flawed. As reported in a Newswise article, Jason Wasserman, author of  At Home on the Street: People, Poverty and a Hidden Culture of Homelessness found that shelters failed to meet the needs of many homeless people because they addressed addiction and mental illness almost exclusively and alienated those who did not have these problems. Wasserman’s research showed that nearly all homeless people want to find work – rather than treatment or even meals.

“Overall, we found the shelters followed a medical model of homelessness, where treatment is required to access services. This puts a band-aid on just a few of the individual symptoms associated with homelessness rather than being attentive to the way society contributes to the problem. In that way, social programs sometimes can make the problem worse.”

As Wasserman argues, the phenomenon of homelessness is indeed a complex one that defies simplistic solutions. Rather than being a homogenous group defined by characteristic symptoms, homeless people demonstrate a wide range of circumstances, abilities and interests; and often a good measure of resourcefulness. For example, contrary to the common stereotype, homeless people in Washington DC are using technology and adding their voices to the blogosphere as captured in this Washington Post article.  Clearly the authors of blogs like “On the Clock with Eric Sheptock” and “Homeless, jobless, hungry N DC ” are active participants in social discourse rather than helpless victims awaiting rescue by social services. They scarcely fit Mark Rabnett’s description of the “hard-to-reach” as “seldom heard” because they represent the collective voice of their community, are engaged in conversations about bettering their lives and can participate in consultations about developing services to meet their needs. The democratizing potential of social media has given a voice to previously marginalized people. An online forum like Streats is a powerful information sharing platform for their community and can be an avenue for connecting with them and researching their needs.  In fact, thanks to social media, these populations are no longer so “hard-to-reach” and we may need to invent other explanations for why they are excluded from social services.

Innovative BC doctors embrace patients as partners Part II

December 15, 2009

A previous post introduced the Patients as Partners Health Literacy Prototype (PAP) sponsored by the British Columbia Ministry of Health Service, Primary Care Division; Legacies 2010; and Impact BC with support of the British Columbia Medical Association.

Four health care teams from four different communities participated in the PAP Health Literacy Collaborative.  They were from Vancouver/Burnaby, the TriCities, Victoria and Hazelton/Gitsegukla. Each participating team was made up of a physician’s office practice and an adult literacy program. The teams  made changes in order to improve health literacy with  gratifying results which they reported during the Get Real: Partnerships for Moving Health Literacy Forward event on December 10 2009. The presentation is available here.

The Hazelton team

  • This unique team brought together Gitsegukla Health Center, Storytellers Foundation, University of Northern British Columbia and the Northern Health Authority – a remarkable partnership. Student nurses provided education and support to community members with high blood pressure.
  • The team wanted to address a unique problem in Gitsegukla. The area is served by newly graduated health practitioners who lack an understanding of the Gitsegukla First Nations culture. To address this problem, they created a cultural primer for health professionals who come to practice in the area so that they can be more sensitive to the cultural needs of the patients. The video will be a valuable tool in the recruitment of physicians.

Burnaby team
To “take patient values and preferences into account,” Dr. Hii’s practice implemented a number of changes with the remarkable results below :

  • assessing and documenting patient’s health literacy on intake by asking questions on formal education, preferred language, English fluency and daily reading habits.
  • use of patient education materials for diabetes self management to ensure patients understand the concepts of ABC (Hemoglobin A1c, BP and Cholesterol) control. They also use the teach-back and “close-the-loop” strategy to enhance understanding although this is very time consuming. More diabetes patients have their blood pressure and cholesterol under control.
  • proportion of patients answering “strongly agree”  to
    • My doctor asked about my ideas, beliefs & what I wanted when we planned my care went up from 30% to 60%. The goal is 80%.
    • My doctor explained things to me in a way that was easy to understand went up from 40% to 70%
    • I felt comfortable asking questions went up from 50% to 70%
    • It was easy for me to tell the doctor when there was something I did not understand went up from 40% to 70%
  • proportion of patients that explained medications and doses as prescribed; did not miss more than one dose in the last 7 days; did not start or stop any medications on their own went up from 70% to 90%.

Literacy learners at Douglas College:

  • learned about H1N1 (at least 10/12 learners could explain what H1N1 is, how it is spread, how to avoid spreading it and what to do if they thought they had it
  • participated in a pedometer challenge to increase their walking as part of a healthy lifestyle
  • learned that nurses were approachable from 3 nursing students who spoke to their class to about the nursing profession


To encourage clear patient-physican dialogue, the Tri-Cities team surveyed literacy (English-as-Second-Language) learners on how they would describe their relationship with their doctor:

  • 17/24 reported that they had a good-okay relationship;
  • 4/24 reported difficulty in talking to their doctor;
  • 16/24 reported having little to no confidence in asking their doctor questions.

The literacy learners suggested that they could improve the relationship with their physician by bringing a family member to an appointment and preparing questions that they would ask the doctor.

The Tri-Cities team assessed the literacy learners’ knowledge and use of the BC provincial non-emergency health information resource (811).

  • 21/28 were unaware of the resource while 7/28 had heard of it but did not know much
  • 26/28 had never used the resource while 2/28 had used the service and found it very beneficial
  • on learning about the resource, 18/25 reported feeling comfortable about using it
  • learners were particularly pleased to know that translation is available  into over 100 languages.

The Victoria team

  • created a prompt card (adapting the It’s Safe To Ask materials) to help their literacy learners communicate with their physicians, ask questions and seek clarification when something was not understood. The proportion of patients with confidence to speak up when there was something they did not understand increased from 3/8 to 7/8.
  • surveyed their patients and found that 28/30 of them did not know which internet sites can give me helpful and reliable information about my health. In response, the practice set up a computer with recommended plain language websites in the reception area. A tracking system was put in place to track use and request feedback on this resource.  90% of the patients used the selected resources. This intervention was in response to the high proportion of patients who brought in flawed information printed off the internet.
  • created a video to help literacy learners navigate their way to the practice location.

The results generated by these teams demonstrate that small changes can lead to significant improvement with far reaching impact on patients’ well being.  The 8 month pilot project has ended but all the teams are determined to find ways to continue the partnerships. Certainly, the participating medical practices will profoundly changed their approach to dealing with patients as they move forward. Their accomplishments can inspire other health professionals to find meaningful changes that could improve their patients’ health literacy. Only a few months ago, in an earlier post, I wrote ” We are a long way from having a robust health literacy strategy like that of Iowa …” so I am thrilled to be proved wrong because the Primary Health Care Charter provides a framework which has been translated into the 3 pronged change package strategy (build relationships, ensure understanding, partner).

Next steps

Some questions remain: what are the characteristics of the practices that volunteered to participate in this project? How can this awareness diffuse from these early adopters to others? How can the Victoria initiative to provide access to reliable online health information be further developed through partnerships with libraries across the province? How can technology be harnessed to empower patients (see my earlier post on e-patients)?  How can the barriers to a wider adoption of patient-centred care be addressed? Many physicians cite time constraints as the biggest barrier to more patient-friendly practice. The physicians at the event suggested these approaches to addressing these problems:

  • organize patient group sessions – for example to teach diabetes self management
  • partner with pharmacists to enhance medication compliance and safety
  • use of volunteer coaches to work with the patient
  • refer patients to libraries for consumer health information (the partnership between Vancouver Coastal Health and Richmond Public Library is an excellent example in this regard)
  • place computers in doctors’ offices to support access to reliable online health information (as in the example by the Victoria practice above)
  • support sharing of tools such as forms and patient resources to avoid reinventing the wheel. A good example is a medical clinic walk-about check-list.
  • involve medical office assistants and other office staff

The common thread in the above suggestions is the involvement of as many players as possible outside the traditional medical community  to extend the physician’s reach in optimizing physician-patient communication. This is a pragmatic approach that seeks to address the reality of overworked physicians in BC. As the awareness is now in place, the next step is identifying creative ways to incorporate these suggestions and other “low-hanging fruit”  in physician practices using the available resources. The ultimate progress will be accomplished when health literacy is considered important enough to merit ongoing and sustainable support across the province.

More information is available from the ImpactBC site or from the Collaborative Co-Directors: Connie Davis, ImpactBC, or Kelly McQuillen, Ministry of Health Services,

Innovative BC doctors embrace patients as partners Part I

December 15, 2009

Dr. Hii’s practice has 4000 patients (really!) but he spends at least 1 1/2 hours with each patient. Dr. Hii is one of BC’s innovative doctors who are embracing patients as their partners. Too often, health literacy is a noble  intention that is seldom translated into actionable strategies. In BC, primary health care practices are making measurable improvements to meaningfully involve patients  in their care. The Patients as Partners Health Literacy Prototype was an 8 month initiative sponsored by the British Columbia Ministry of Health Service, Primary Care Division; Legacies 2010; and Impact BC with support of the British Columbia Medical Association.

On December 10, they invited the health literacy community to the Get Real: Partnerships for Moving Health Literacy Forward event to show case what this initiative has accomplished. It was fascinating to learn how different teams had worked together to accomplish significant health literacy outcomes. There are excellent videos showcasing the work done so far. The title of the video Nothing about me without me captures the spirit and lofty goal of the PAP program.

Below, are a few highlights that are instructive to anyone seeking to develop and inform health literacy interventions.

  • The Patients as Partners(PAP) program is  underpinned by BC’s primary health charter.  The charter identifies one of the seven priority areas for primary health care system change as “building supports for patients as partners.”  The charter provides a clear contextual framework and lends important legitimacy, credibility and potentially, resources to health literacy initiatives.

Key lesson: isolated health literacy efforts not backed by such a broader framework are unlikely to accomplish system-wide  improvement.

  • The PAP program created integrated teams that sought to improve health literacy in their practice settings. Each team consisted of a physician’s office practice and an adult literacy program. The adult literacy program included instructors and adult learners.
  • Four teams from four different communities participated. They were from Vancouver/Burnaby, the TriCities, Victoria and Hazelton/Gitsegukla. These teams represented common challenges faced in health literacy, such as immigrant populations, a First Nations community, a rural site and three urban locations.

Key lesson: It takes integrated teams to address health literacy issues.

  • One of the greatest challenges in the PAP project was bridging the huge cultural disconnect between the literacy & health care communities. This is telling (and not too surprising) because it implies that the primary health care community is not attuned to literacy issues which underscores the value of the partnership.

Key lesson: Bringing the medical and literacy cultures together can be a challenge and requires flexibility, adaptability, trust and openness.

Health Literacy Umbrella

Umbrella is a fitting analogy for health literacy strategy

The PAP program enhances health literacy through the 3 pronged change package strategy cleverly illustrated by an umbrella that protects patients from health problems and risks.

  • Build relationships: Take patients’ values and preferences into account; Provide a relaxed, friendly, respectful atmosphere
  • Ensure understanding: Use plain words, clear and culturally relevant pictures; Encourage clear dialogue between patients and health care team; Follow-up after a new diagnosis, medication or planned chronic care; Use technology; Make health care setting easy to navigate
  • Partner to support better health: Provide peer support; Use meaningful community resources; Provide health literacy education

Key lesson: A successful health literacy strategy needs to entail action-oriented effort

  • Collaborative improvement approach prompted teams to think critically about what changes would bring about improvement and how they could be measured. They asked 3 questions:
    • What are we trying to accomplish?  (Aim is to improve health literacy)
    • How will we know that a change is an improvement? (Measures)
    • What changes can we make that will result in an improvement? (Good ideas for improving health literacy comprised the “change package”)
  • The teams used the PDSA cycle to test the change ideas:
    • Plan: who, what, where, data collection
    • Do: carry out plan, document problems and observations, collect data
    • Study: complete analysis, summarize lessons learned
    • Act: What changes should be made; next cycle

Key lesson: The ideal approach encourages small scale experimentation with imperfect ideas; eliminates fear of failure as emphasis is on learning; identifies measurable changes, supports data collection and recognizes that the improvement journey is not smooth.

It is very inspiring to learn that the Patients as Partners program teams explored at least three changes some of which led to outstanding and sustained health literacy improvements. Team results are presented in another blog posting.

Image credit: Developed by the Health Literacy in Communities Prototype Faculty.

How health care system fails ePatients

December 8, 2009

E-Patients actively seek health information online

As the terms “e-health” and “e-patient” entrench themselves in health care lingo, some may dismiss the growing interest in this phenomenon as a passing fad. Yet, technology is profoundly transforming not just the way in which health care is delivered but the very nature of healthcare itself.  The seminal white paper e-Patients: How They Can Help Us Heal Healthcare brilliantly argues that this change parallels the radical revolution that marked the transition from the Industrial Age to the Information Age. Automation resulted not in robots working in factories but knowledge workers using computers; in other words, beyond shifting the mode of work, technology transformed the nature of work itself. By the same token…

…bringing healthcare into the new century will not be merely a matter of automating or upgrading our existing clinical processes. We can’t just automate earlier forms of medical practice. The underlying nature of healthcare itself must change.

There is a growing acceptance that the Industrial Age paradigm, in which health professionals were revered as the exclusive locus of medical expertise, is shifting to one in which patients, families and consumer networks are increasingly viewed as important healthcare resources. It is easy to take for granted how much technology has catalyzed the meteoric rise of the e-Patient. We may overlook the now shocking reality that as recently as 1994,  Edwin Murphy ( a patient with a chronic hip problem) had to impersonate Dr. Blakely ( his physician) to obtain an article, on the risks and benefits of a proposed surgical procedure, from the hospital library. His doctor had ignored his repeated requests for the article. The internet broke down the barriers, allowing patients entry into the hallowed corridors of  medical knowledge and decisionmaking, whether or not health professionals were ready for them.

While some doctors remain rooted in Dr. Blakely’s era,  their progressive counterparts (about 22%, 2006) are embracing their patients as partners – welcoming their initiative to research their condition online, analyze their options, connect with patient communities and participate actively in their own care. However, access to health information is only one tenet of the complex entity that is health care. There is is still a lot to be done because the current system as a whole is predicated on the Industrial Age paradigm. There is a disconnect between e-Patients’ capacity to participate in their health and the system’s capability to support this. Progressive physicans who are willing to engage with their e-Patients are hampered by a healthcare system that is modelled on outdated pre-Internet medical constructs. There are abundant barriers to:

  • Physicians communicating with patients via e-mail and mobile technology on a 24/7 basis
  • Interoperability for efficient patient data exchange to optimize health outcomes and safety (see Towards Health Information Liquidity)
  • Patients obtaining access to their medical records via the Internet
  • Referring patients to online support communities
  • Involving patients in assessing the evidence and using it to inform their decisions

While cultural and institutional obstacles impede patient-physician collaboration, the reimbursement model is a particularly significant barrier to participatory medicine.  Describing the US system, Rushika Fernandopulle and his colleague Pranav Kothari state,

“In the traditional clinical practice, the insurance company comes first, the provider institution comes second, physicians come third, nonphysician staffers come fourth, and the patient comes last”

Insurance companies choose to not pay for communication via e-mail and access to electronic health records. Fernandopulle and his colleagues see the retainer-based practice model as a way to break free from the restrictive tyranny of cost-containment and to embrace a far more patient-oriented  approach to clinical care. I am sure there are other innovative health practitioners that are creatively seeking ways around systemic barriers in order to harness the potential of technology to better serve their patients.

As these isolated visionaries take the lead, the US health reform process underway is a prime opportunity to undertake the radical revolution envisaged by Tom Ferguson, MD:

“Something akin to a system upgrade in our thinking is needed-a new cultural operating system for healthcare in which e-patients can be recognized as a valuable new type of renewable resource, managing much of their own care, providing care for others, helping professionals improve the quality of their services, and participating in entirely new kinds of clinician-patient collaborations, patient-initiated research, and self-managed care.”

While this post focuses on the US situation as articulated in the ePatients White Paper, the rise of the ePatient is a global phenomenon so similar scenarios may be playing out elsewhere. Most health communication professionals are keen on addressing the barriers to e-health technologies. Your insights on how to confront these issues are most welcome. To discuss these issues with passionate e-health enthusiasts, join the weekly #hcsm Twitter conversation held on Sundays, at 8:00 pm, Central Time.