How do the bosses think Yellowknife primary care is doing?

Almost a year has passed since a major reorganization of Yellowknife primary care, taking 10 teams of staff – and a lengthy waitlist – and transforming that into just four larger teams instead.

Yellowknife also has a new base for much of its primary care, the Łıwegǫ̀atì building that opened last year inside what was once the city’s hospital.

So there’s a new facility and a new plan, but some familiar problems have persisted. (Surveys are now rolling out in clinics to learn more about how patients see things.)

Staff have expressed uncertainty about the change in approach and whether it has the resources it needs to work. Patients have found booking appointments near-impossible, leading the health authority to acknowledge “significant frustrations” and promise new approaches.

In October, MLAs released findings from a survey that they said demonstrated a healthcare system “on life support.”

Meanwhile, healthcare leaders said their change to four teams in Yellowknife needed time to pay off – and they would keep evolving the system as challenges arose.

“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 territorial medical director Dr Claudia Kraft last summer.

So how about now?

We asked the people in charge – Kraft and Jennifer Torode, the health authority’s chief operating officer for the Yellowknife region – how they think things are going and what might happen next.

What’s the overall goal?

The change to four teams and other adjustments are part of what managers call primary healthcare reform.

They see this as a broader project to decolonize healthcare and make sure it’s culturally safe while ensuring it is high-quality and meets patients’ needs.

Kraft said the health authority is trying to juggle various elements to “march ourselves bit by bit towards that goal.”

More: NWT working on rural healthcare ‘strengths and weaknesses’

The major goal in Yellowknife is to improve access, meaning finding a way to make it easier for you to get healthcare. There is an acknowledgement that never being able to nail down an appointment time, or having to line up for hours in the hope of a walk-in slot, is not the right set of outcomes.

“We all know it can be really difficult to find your way to the right healthcare provider in Yellowknife, and the challenges are in having a relationship with a care team that knows you over time,” said Kraft.

“People don’t want to tell their story over and over again. They want to be known. They want someone to understand that when they call the clinic for the third time in a day, it’s because they’re actually really worried about that result from the ultrasound.”

Family doctors are out, family teams are in

Central to the health authority’s approach is moving people away from “I have a family doctor” toward “I have a team that looks after me.”

Just over half of the NWT’s family physician positions are vacant. As of mid-February, there were about 57 full time-equivalent funded positions in the territory, of which 27 were filled according to health authority data. Those physicians aren’t just dedicated to primary care – included in those figures are physicians who also cover emergency medicine, inpatient medicine, anaesthesiology, chemotherapy, abortion care and birthing care, among other roles.

Without enough full-time staff doctors who live in the NWT, the health authority is attempting to create a system where the emphasis is on who your team is, not who your doctor is – and on accessing the team, not necessarily the doctor.

“In traditional models of primary care, the family physician is often the gatekeeper for any of the resources that a person might need,” said Kraft.

“In team-based care, the care a person gets is care that’s the right care by the right person.”

Trying to reach your family doctor for every concern is now an “old-school model,” said Kraft. The new way involves sending you to whoever in the team is the most useful, freeing up doctor time for other patients who might be in more need of a doctor’s help.

“When what’s needed is a doctor, then the doctor is brought into the team. When what’s needed is a mental health counsellor or diabetic education specialist or a foot care nurse or home care nurse, or an LPN for immunizations, or a nurse specialist on preventative care, then that’s who they might see,” said Kraft.

How are the four teams working out?

It’s fair to say the switch to four larger teams has illuminated some gaps.

Firstly, the move made clear that the way patients were previously assigned in Yellowknife operated with “no rhyme or reason,” said Torode, the chief operating officer for the region.

When you’re assigned to a physician, that’s called panelling. In Yellowknife, over the years, you could find yourself panelled directly to a specific doctor, panelled to one of the 10 old teams, or not panelled at all, wandering around in a column called “the unassigned.” What kind of healthcare experience you got could vary greatly, Torode said, based on which of the above buckets you fell into.

Sometimes, someone would end up assigned a family doctor “simply because they gave birth,” said Torode, “as opposed to someone who has cancer, who has multiple comorbidities and who really needs to be seen.”

As things have evolved over the past year, Torode said, a new regional committee has been created alongside new working groups to try to improve how everyone works together.

“There’s a lot of inefficiency that has historically been built into this. As a result of moving to four teams, it’s really become apparent all the things that have been sort-of sitting there percolating in the background, that people haven’t been aware of,” she said.

Kraft said the four teams are now “equally resourced,” though that doesn’t necessarily mean fully resourced. She said whichever team you’re assigned to should now have “essentially the same resources to try to tackle their population’s needs.”

“We no longer have ‘haves’ and ‘have nots,'” she concluded.

What’s next?

Kraft said the health authority is now working to understand which “specific gaps” need priority attention after almost a year under the new system.

“It’s not to say that we think the makeup of each of those teams is necessarily what it’s going to look like two years from now, or what it ought to look like,” she said.

Torode added: “One of the pieces that I think is incredibly important for us is to work with educating our public on: what does it mean to receive quality care from a team? And to manage those expectations that a physician has to broker every experience you have.”

In other words, if you previously got to see a family doctor every time you went to the clinic, those days may be over. The health authority says this will not be to the detriment of your care.

“There would be some people who have been accustomed to really privileged access to the doctor,” said Kraft.

“In the new system, they are going to end up giving a little bit more of their share of that doctor resource so that doctor is available to look after somebody who maybe has never gotten to see the doctor, but really needs it because of their new cancer diagnosis.”

Torode hopes patients will “recognize the value of the host of professionals that work within the clinic, that have the scope of practice and the expertise to be able to provide for those needs, often in ways that are better than they may have experienced with their physicians.”

“It’s a little bit like a steam train,” Torode said of the primary care system overall and the work of transforming it.

“It takes a lot of shovelling to get this thing going. But I think we are beginning to see some benefit of it and beginning to pick up steam.”