Primary Care Network (PCN)
A PCN is a clinical network of local primary care service providers located in a geographical area, with patient medical homes (PMHs) as the foundation. A PCN is enabled by a partnership between the local division of family practice and health authority, along with local First Nations and Indigenous partners.
In a PCN, physicians, nurse practitioners, nurses, allied health care providers, health authority service providers, and community organizations work together to provide all the primary care services a local population requires.
Participation in a primary care network enables a patient medical home to operate at its full potential. In a PCN, patients get access to timely, comprehensive, and coordinated team-based care, guided by eight core attributes (Family Practice Services Committee, 2020).
To learn more visit: Primary Care Networks | FPSC (fpscbc.ca)
Specialized Community Services Program for the Complex & Medically Frail (SCSP-CMF)
This model of health care delivery supports the patient's journey from Acute Care to Community, or from independent living to fully supported needs.
When patients require more specialized health care services related to mental health and substance use, surgery, cancer care or managing complex medical issues and/or frailty, they should not be left to find their way between multiple services, multiple wait lists and multiple providers resulting in suboptimal, uncoordinated and inefficient care (Divisions of Family Practice JCC Resource Catalogue, 2018, para. 3).
The SCSP model involves a most responsible clinician (MRC) who coordinates and collaborates with the various programs required to support the client in Community. The care delivery model is a team-based "...holistic, comprehensive, and coordinated ..." (Divisions of Family Practice JCC Resource Catalogue, 2018, para. 4) approach aiming to wrap around the coordinated services based on the "needs of the individual patient and their family resulting in a quality service experience"(2018, para. 4).
Community Health Nursing -
What is a Community Health Nurse?
The Community Health Nurse (CHN), is a
Registered Nurse [who] works independently in the community setting. [The CHN] Works collaboratively and as a member of an interprofessional team in the management of an assigned client caseload including assessments, coaching, interventions, client care services and follow up to enable clients and their families to live confidently and safely at home and/or community; emphasizes the promotion, maintenance and restoration of health such as the treatment of chronic diseases through teaching, counselling and direct client care; facilitates and manages client transitions across the healthcare continuum utilizing the provincial Primary & Community Care model to optimize recovery or adapting to changes in the client's condition to minimize avoidable admission to residential and/or acute care facilities; collaborates and ensures linkages with acute, primary and community care healthcare providers including the client's primary care provider (Nurse Practitioner, Physician, other specialist(s)) and family/supports regarding client care planning; supports clients and families, as client care is transitioned to primary/community care provider including FH and non-FH community services (Recruitment Fraser Health Authority, 2023).
A range of integrated home and community-based professional and caregiver services to help you remain independent at home for as long as possible. No matter where you find yourself on your care journey, we will help connect you to the right services.
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All community-based professional services will help coordinate and connect you to programs and services, as needed, including other health services and community resources.
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Learn more about our community-based professional services as well as our caregiver and family support services here.
The Canada Health Act (CHA or the Act) is Canada's federal legislation for publicly funded health care insurance. "The aim of the CHA is to ensure that all eligible residents of Canada have reasonable access to insured health services on a prepaid basis, without direct charges at the point of service for such services (Health Canada, 2023).
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Collaborative work is already underway with provinces and territories to help support access to home care and long-term care. This includes existing investments of $6 billion for home and community care and $4 billion to improve the quality and safety of long-term care. Included in the investment ... is an additional $1.7 billion over 5 years to support wage increases for personal support workers and related professions (Government of Canada, 2023).
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The Home and Community Care Service program delivery evolution and a constant engagement with the community residents and seniors’ groups, demonstrates routine modernization of the Canada Health Act.
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In my 28 years of nursing, I have experienced variations in delivery models and aspects of the Nursing role being either full-scope or specialized. However, when it comes to the entitlement of funded services, there has mostly been a consistent requirement of eligibility for accessing certain services such as the Older Adult Day Programs, Long Term Care Facility placements, or long-term Home Support Services. Access to those programs has always required a RAI-MDS assessment, and a financial assessment to determine either sliding scale payment or a pro-rated flat rate based on the client/patient’s income level. The RAI-MDS "is a database that captures longitudinal, demographic, administrative, clinical, functional, and utilization information on clients who receive publicly funded home care services. The HCRS contains data on clients at multiple points throughout clients’ home care services" (University of British Columbia, 2023). Clients on Guaranteed Income Supplement (GIS) (Employment and Social Development Canada, 2023), or Persons With Disabilities (PWD) sources of income are eligible for free services (Van Vloten, n.d.). However, at the time of needing facility placement, the client would still have a specific minimal rate to pay. "[To] receive publicly subsidized long-term care services ... a monthly rate [is charged] of up to 80 percent of [the client's] after-tax income towards the cost of secure, supervised housing and care services, subject to a minimum and maximum monthly rate" (Government of B.C., 2023). More information on community-funded services can be found here.