What health bosses say they’re trying to achieve in Yellowknife

“I have met many patients who’ve almost apologetically said, ‘I know I don’t really need to be here.’ But of course they do, because they couldn’t find an appointment in a timely way.”

Dr Claudia Kraft is the territorial medical director in the NWT. She’s also an emergency physician, and she’s used to patients turning up in the emergency room because they couldn’t get a regular doctor’s appointment.

Kraft is one of the senior managers helping to set the direction of healthcare across the territory and in its capital, Yellowknife, where primary care recently underwent a significant shift.

Previously, Yellowknife residents were placed on one of 10 different healthcare teams or on a 2,000-person waitlist that was years long.

Since the start of the summer, staff have been redeployed into just four larger teams. Every resident can be assigned to one of those teams rather than left on a waitlist.

In theory, that sounds great. The waitlist will go away and everyone has a team of staff they can reach.

In practice, it hasn’t been that simple. Redesigning the teams still leaves essentially the same number of staff and the same level of capacity, but now the system and its workers have to adapt, patients have to adapt, and there’s no guarantee of anyone being seen any quicker.

That means you’re still left with options like sitting for hours in a waiting room for a walk-in appointment, phoning in a mad rush at 8:05am to be one of the lucky ones that secures a same-day slot, or listening to a voicemail that tells you someone will call you back, only to be eventually told there are no appointments available right now.

The inability to easily access appointments is frustrating for patients. Trying to support a system that’s at or above capacity is a grind for staff. The end result is what Kraft sees when patients simply show up at Stanton Territorial Hospital’s emergency room instead.

More often than not, ‘”they were right” to do that, Kraft said in an interview earlier this summer as the new four-team system rolled out.

“We never want people to think they are making a wrong choice by coming to the emergency department. We don’t turn people away,” she said.

“Sometimes, the triage staff will try to navigate on behalf of that patient. They have access sometimes to additional primary care appointments. But absolutely, if a person thinks they need to be seen in the emergency department, and they aren’t sure where else they can get care, the emergency department is the right place for them.”

This is the third in a series examining healthcare issues in the NWT. In this article, we focus on what managers say they’re trying to achieve with recent changes. In our next article, front-line staff will tell us how they think those changes are working out in practice.

We asked Kraft and Kim Riles, the NWT health authority’s chief executive officer, to walk us through why the Yellowknife primary care system changed. What problems does the redesign of the system seek to solve, and how?

“Whether or not they’ve had an assigned provider or an assigned team, people often are challenged to find an appointment in primary care. Some people come day after day, on the phone or in person, looking for an appointment,” said Kraft.

“These are precisely the navigation challenges we’re aiming to solve over the next few months with primary care reform.”

‘A medical home for every resident’

Getting Yellowknife primary care right is important.

If you live in a smaller NWT community, you’re unlikely to shed a tear for Yellowknifers struggling to book appointments. Finding a doctor elsewhere in the territory is just as difficult, if not far more so. Much more delay, travel and associated hassle can be involved.

But if Yellowknife residents are clogging up the emergency room because they can’t see a doctor at a clinic, that has an effect on the availability of care for people across the NWT.

Managers certainly see a better-run primary care system as a means of easing some pressure on Stanton Territorial Hospital, which has existed at or near “gridlock” – a term meaning the hospital’s inpatient beds are full and the emergency department has nowhere to move patients – for many months. (We’ll come back to that later in the series.)

There’s a second way that better access to primary care can help the whole system.

If it’s easier for you to get help when a problem isn’t that big a deal, that problem is less likely to become a major condition that needs more of the healthcare system’s resources. If your primary care clinic keeps you healthier, the rest of the system breathes easier.

That can’t happen if you can’t get an appointment.

This is a key reason for wanting to be able to assign every resident to a team of healthcare workers rather than have 2,000 people on a waitlist (never mind the unspecified number who hadn’t even signed up for the waitlist).

“A medical home for every resident in Yellowknife, that’s one of our stated goals,” said Kraft.

“When everybody has a medical home and a team behind them, then we are confident that some of the navigating to primary care will be easier for folks that are facing that challenge right now.

“That should enable us, within each of those teams, to find better ways to address some of the chronic medical conditions that we know, when they’re not addressed at the primary care level, end up with the potential for causing admissions at the other end.”

The switch to four teams and the plan to assign every patient to a team was announced in late May, just as Yellowknife primary care workers moved en-masse into the Łıwegǫ̀atì building – the renovated old hospital building that has been refitted in part to serve as a primary care hub.

Three months later, you would be hard pressed to find a Yellowknife patient who says things are now markedly easier. Cabin Radio continues to hear regularly from patients who have had trouble getting the standard of care they think should be available.

“We’re not pretending, on our first patient day with four teams in a new facility, that this is the switch by which we’ve solved all of the problems for access to high-quality care in Yellowknife,” said Kraft.

“But it is a key enabler. A foundational step for us is having equally resourced, equitably resourced teams with more redundancy.”

Pockets of access

The level of resourcing is the second big pillar of the new system, and the reason for the move from 10 teams to four.

Previously, not all of those 10 “mini teams,” as the health authority called them in May, even had regular access to a physician. Different teams had different levels of staffing and resources, which managers say meant the level of care offered to patients was meaningfully different by luck of the draw.

“What we used to have was a lot of different teams with really variable staffing. Not all teams had reliable access to a physician, for example,” said Kraft.

“Not all teams had a community health nurse capable of doing assessments, case management, and some of the complex tasks at the top of nursing scope. Most teams didn’t have any capacity to backfill in their program assistant roles or licensed practical nurse roles – they were one person deep across the board.

“Moving into four teams enables us to have four more evenly resourced teams that can each define the work and the population and the healthcare needs within that group. It also allows us to more reasonably ensure, with our staffing and management model, that each member of each team has the daily access to the consultant – the family physician – that they need.”

In other words, four teams who can each tap into a physician each day can get more done because more people are helped to work at the height of their powers by having the right network of supporting staff.

The theory is that if more people are working at the height of their powers, they can probably see you and get you the treatment or advice you need – even if they aren’t a physician – because they can always go quickly chat with the physician if they need to.

Kraft gave some examples.

“A licensed practical nurse seeing somebody for an allergy shot who has a question before they perform that procedure” will benefit from ready access to a physician, she said.

“Or a community health nurse who is seeing somebody for a rash and they just want another set of eyes to make sure they’re on the right track, or a nurse practitioner who’s managing somebody with complex cancer diagnosis, and they want to think together with a physician about some of the impacts of the antibiotics on the chemotherapy drugs that patient is taking.”

In each of those instances, Kraft said the aim under the new system is for those staff to have “between one and three different physicians each day on that team that they can talk to.”

If this works, it eliminates what she calls “pockets of access.”

Week by week, month by month

Riles, the health authority leader, said this is one way to reinvigorate a “primary care system that’s already feeling like it’s tapped out” to patients.

“Some of the work that’s being done is really about making sure the right people are doing the right types of jobs,” Riles said.

“Do you need to actually see a physician to have your form filled out? Or can that be done by someone else and free up that physician spot for someone who needs a chronic disease monitored, or has a really complex medical situation that needs to be sorted out, or a procedure that can only be done by a physician.”

Meanwhile, with more access to physicians, Riles said other members of the team can “do things that may actually in the past have required a sit-down dedicated appointment with a doctor, but rather could instead be seen quite effectively by a nurse with perhaps a hallway consult with a doctor just to confirm the plan.”

Managers insist that if you look closely, there have been some wins in Yellowknife healthcare.

Kraft points to what she calls a “real increase in the number of same-day or extended same-day access appointments” in recent years.

“We have been offering about 500 same-day access appointments every month within the clinics. We know that if we could shift that a little bit and make some increases, or have a little bit more accessible urgent-type care, that can offset some of the visits that come to the Stanton emergency department,” she said.

Equally, Kraft acknowledged that the reshuffle into four teams “doesn’t solve the problem of how many total appointments are available to us in the system,” nor how many staff are available in total.

“But it does really help us to take those next steps” of identifying where the upgrades need to happen, she said. That might be one team identifying “unmet needs for diabetes management” or “more resources for addiction management.”

“And then we can figure out what’s the best way to resource it,” said Kraft.

“We are going to be in a much better position week by week, month by month, as we move forward with primary care reform, for solving these problems and addressing some of the barriers.”

Also in this series

August 22: NWT restrictions on physicians leave patients ‘really vulnerable’

August 23: At a health town hall, patients see nuance even as they endure pain