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Primary Care Transformation

Primary Care Transformation is one of four priority initiatives included in the Grande Prairie PCN's 2020-23 business plan renewal. This initiative addresses the need for focused engagement and facilitation support to enable practice and system level transformations that align with provincial PCN Objectives and North Zone (NZ) planning priorities. This initiative will address the continuing need to facilitate practice level changes in primary care delivery in line with the Patient's Medical Home model of care. PCN staff will increase their focus on enhancing team-based care by supporting collaboration between physicians and PCN team members and working more directly with AHS on advancing NZ transitions of care initiatives at the local level.

Four operational elements are included in this initiative:

  • PCN Transformation Team – A team of PCN staff including a Transformation Lead, Practice Facilitators and a Nurse Liaison who, together, support primary care transformation activity.

  • Physician Learning and Engagement – The PCN will coordinate and host touchpoint events focused on primary care transformation topics. The PCN also supports physician engagement in Family Medicine rounds through this element.

  • Practice Transformation Program – This program provides practice-specific support for transformation engagement and activity towards PMH implementation within member physician clinics. The program is comprised of three streams of support: Foundations; Projects; and Team-based Care Integration. Team-based Care Integration allows member physicians to choose to complement their clinical team with a PCN employed Licensed Practical Nurse, Registered Nurse, or other allied health professional based on a service plan that reflects identified service needs of the physician(s)' panel of patients.

  • Primary Care Transformation Advisory Committee – This committee provides oversight and guidance respecting the implementation of the Primary Care Transformation initiative. The committee is comprised of physician members and other individuals appointed by the Board of Directors.

Community Information Integration / Central Patient Attachment Registry (CII/CPAR)

The Grande Prairie PCN is leading the North Zone in implementing the new Provincial Initiative CII/CPAR.

Community Information Integration (CII) is a system that transfers select patient information between community Electronic Medical Records (EMRs) and other members of the patient's care team (family doctor, specialists, etc.) through Alberta Netcare. The Central Patient Attachment Registry (CPAR) is a provincial system that captures the confirmed relationship of a primary provider and their paneled patients. Together CII/CPAR will enable health system integration and improved continuity of care that are essential and foundational change elements in the implementation of the Patient’s Medical Home model of care.

Dr. Olubukola Maxwell is the first family physician in Grande Prairie to adopt CII/CPAR in their practice.  Dr. Maxwell and her clinic staff have invested time in panel identification, maintenance processes, and have completed the CII/CPAR Panel Readiness Checklist, as well as all the prerequisites for participation.
“Continuity of care is so important to us as a clinic, it trumps many other objectives.  When we set up the clinic it was a bit of a shock to realize patients could ‘double doctor’,” said Dr. Maxwell. “An idea that was not only alien to me but also found quite difficult to work around.”

Dr. Maxwell was eager to adopt CII/CPAR.

“Of course, we could not wait to jump onto the proverbial bandwagon when CII/CPAR was introduced,” she says. “Not only is it an enabler of continuity of care for us, it helps us receive notifications when our paneled patients attend the ER.”

Dr. Maxwell can see the positive impact on the future of her practice, and the quality of care she can give to her patients.

“CII/CPAR stands to help us better plan our service provision reliably.  With CPAR being a central registry,” Dr. Maxwell said, “it enables us to know exactly who our patients truly are. CII/CPAR prevents duplication of services. It’s also more like a one-stop-shop approach to patient healthcare records which enables timely care and minimizes errors.”

“I am hoping more adopters take up this long-awaited initiative, especially within our community.”

CII/CPAR is the next logical step to promote a coordinated care management approach to service delivery and achieve better patient, provider, and system outcomes. Healthcare providers will be able to access selected patient data in the Alberta Netcare Portal to get a clearer picture of the care the patient has received from the family physician and other community care providers.

Click HERE to learn more about CII/CPAR.
Click HERE for a list of frequently asked patient questions.