Plan

You will need to gather, capture and analyse patient information to make solid planning decisions. You’ll also need to determine how to connect patients with needed services in your community.

Orient Patients​​​

​Understanding the social and economic challenges patients are experiencing requires asking questions about their living conditions. Patients may wonder why they are suddenly being asking about their income, housing or social networks by their doctor. The PREPARE chapter on how to Engage Key Stakeholders provides helpful approaches and messages for this step.

Survey Patients

To determine progress, you need to know where the clinic is now. Engage in the PSP Baseline Patient Satisfaction Survey, available from local PSP coordinators, or borrow Kootenay Boundary Division’s version. Make sure to include SDH questions in the survey.

Learn About Your Community

Familiarize the team with your community’s SES profile (NOTE: The SES profile website does not work in the Safari browser.). Profiles have been prepared for each community in BC, including information on overall socio-economic index, health issues, education concerns, children at risk, youth at risk, crime and human economic hardship.

Learn About Local Programs and Services Available to Patients

Use ​http://bc211.ca to review a list of services available in your area, or call 211 (Metro Vancouver, Fraser Valley, Squamish-Lillooet and Sunshine Coast) to get advice from bc211 Information and Referral Specialists, trained in social work and intake processes.

Access databases of local community services and programs, if available, through the local Division of Family Practice. For example, kb.fetchbc.ca for the Kootenay Boundary.

Plan for a collaborative, team-based practice

Physicians have a crucial leadership and clinical role to play in embedding the SDH into their clinic, but much of the leading practice associated with this work is not top of scope for a doctor.  It is critical to build a team around your patients, which includes allied staff with expertise in the behavioral aspects of primary care, and connect patients to relevant community resources.  As new funding becomes available for PCN clinical team members, consider roles and related skills with titles such as Nurse Educator, Social Worker, Behavioralist and/or Health Coach. Resources to explore include:

• KB Division’s Primary Care Social Work Pilot, describes the practice of integrating a social worker into the medical clinic setting
• A Guidebook of Professional Practices for Behavioural Health and Primary Care Integration from the Agency for Healthcare Research and Quality – Download the Executive Summary or visit the Team page for the full report)
• Multiple resources from the BC Association of Social Workers outlining the role of Social Workers in Primary care – check out this PDF or this brochure

Remember as you begin to consider recruiting into these positions to develop a health team that reflects the demographics and health needs of your community.

Know the basics about SDH & Quality Improvement

A robust QI framework will be an integral component of any PCN journey, and approach to integrating SDH into clinics. PCN Change Support Staff will support you in this work. PREPARE provides interesting context on how to Develop a Data Strategy and Understand and Evaluate the Data as the team moves forward.​

Prepare an Implementation Plan

The process described above and in the following steps, involves substantial logistics, change and project management. In a busy practice, it is important to know who will implement what, and at what point in the patient visit. An implementation plan for the clinic will outline required actions, responsibilities and timelines. It will help ensure that the right systems and protocols are in place.

• PCN Change Support Staff will assist you with drafting this document.
• The PREPARE chapter on strategizing the implementation process will help.