Primary Care Lays Foundation for Better Health
Categories: Primary Care,
In “Laying the Foundation" Primary Care Network nurse Lacey Smoole describes her experience with a young man with diabetes in her community.
"I remember entering the consult room and greeting Mark, who wore a big, oversized toque and a giant smile,” Lacey shares, “As usual, he seemed engaged and eager to manage his diabetes, but as we started reviewing his home readings and lab work together, I knew that things were still the same, if not worse. His blood sugars were wildly out of control. I really wanted our discussion that day to be different — I didn't want him to live the rest of his life with the potentially terrible side effects of unmanaged diabetes.”
Asking Non-traditional Questions
In healthcare, we measure, monitor, and screen for many health indicators. How many of us screen for the biggest factors impacting health such as financial strain? Primary Care Providers have started to shift toward understanding a more fulsome picture of what is influencing health. They started by asking patients, “Do you ever have difficulty making ends meet at the end of the month?” On paper, this sounds like a simple change, but in practice, it opened practitioners and patients to important conversations around income, poverty, and health. Each clinic team added other important questions that were applicable to their populations.
“Everyone struggles with some sense of financial strain, whether you're a business owner, a service provider, or an individual. And I think that's an awesome place to start a conversation,” says Dr. Mary Modayil (Scientist in Primary Health Care with AHS).
Lacey discovered the power of this kind of question when she began to ask Mark for more details on his situation.
“Have you been taking your insulin, or have you forgotten any doses?”
“Nope,” Mark replied, “I have been using the long-acting and taking my short-acting with meals.”
“Okay, what have your meals been looking like?”
“Well, I usually skip breakfast. I don't really snack at all, and I usually have a big bowl of soup or noodles for dinner.”
“Can you tell me a little bit more as to why you typically eat this way?”
“Well, it's half habit, half necessity.”
The “Aha” Moment
“Suddenly,” Lacey says, “it was like the lights turned on in the clinic room as Doctor Joseph (Ojedokun) and I both stopped and looked at each other. We had been working on a project for the past few months about reducing the impact of financial strain (RIFS) on people's health, and that phrase ‘half necessity’ took on a whole new meaning.”
“We paused for a long time as our treatment plan whirred through our minds. We had planned to refer Mark to a retina consultant, a healthy living class, a dietician and were already thinking about different interventions we could use to mitigate his progressing diabetic complications, but instead, I turned back to Mark and asked, ‘what do you mean out of necessity?’”
“He squirmed a bit, coughed, and with an awkward smile said, ‘well, I don't have that bursary for school anymore, and I haven't been able to find a job yet, and my mom lost her job recently, so we just don't have a lot of money for food right now.’”
How might we work more upstream?
Over the next month of weekly meetings with Mark, Lacey’s team helped Mark apply for Alberta Works, provided him letters of support for various government programs, brought in his sisters to expand his support network, and arranged for his medication coverage. In one of these meetings, they talked about his goals for the future. He had been studying to become a lawyer. He said he didn't come from much, but that he was going to break that trend.
“Later in that meeting,” Lacey says, “we found out that he hadn’t been accessing the food bank yet and Doctor Joseph said, ‘Mark, no one reaches their goals alone. Most people need help at different times in their lives. We want to see you succeed. You need to access the food bank.’” They discovered how important it was to access the many supports in their community.
Laying the foundations
Three months after the first pivotal meeting, Mark is now eating regular meals, and Lacey, her team, and the newly expanded community team found that Mark was ready to have valuable conversations around discussing meal planning, retinal treatments, resume support, and working with a chronic disease nurse.
“We had to lay a foundation,” Lacey concludes, “before putting up the walls and the roof and, just like Mark, we needed the support of other community agencies to do that”
How might primary care address financial strain
Many health care teams like Lacey have witnessed how important it is to lay a strong financial foundation in order to productively prevent and address chronic health challenges like diabetes.
In April 2018, Alberta Health Services received funding to co-design and implement Reducing Impact on Financial Strain with communities and PCNs. During the pilot project three PCNs, including Lacey's, began the process of screening for financial strain, community asset mapping to link clinical and community supports, assessing services and opportunities, and developing infrastructure to sustain supportive partnerships.
“What we’ve heard from some physicians,” Lisa Kemp (Manager, Primary Health Care, North Zone, AHS) tells us, “is that even if they felt comfortable with the conversation, they didn’t feel they could address it because they didn’t have solutions. As a result, some formed teams where they’d reschedule patients into complex appointments with the RN and a social worker.”
How might we start the shift to talk about financial strain. #StartTheShift
Dr. Joseph Ojedokun of the McLeod River PCN, the same clinic where Mark’s journey with diabetes forever changed, stresses the importance of shifting medical care towards a holistic approach. “Ask what matters. Listen to what matters. Do what matters.”
By embedding screening questions, opening life-changing conversations, and establishing relevant community connections, the Life Medical Clinic and the McLeod River Primary Care Network (PCN), where Dr. Joseph and Lacey both work, have recognized the enormous potential to improve health outcomes for Albertans and has been honoured with a Patient Experience Award from the Health Quality Council of Alberta.
How have you started this life-changing conversation with your patients?