How doctors and service providers in Burnaby are working together to do primary care differently

Health and wellness care that’s focused on the individual needs of a neighbourhood, with a team of providers surrounding a particular patient and providing them with personalized services: that’s the driving vision behind Burnaby Primary Care Networks (PCN).

The network comprises a group of physicians, clinicians, and administrators who collaborate with Fraser Health and with community organizations, with the aim of expanding beyond medical care and providing social services as well.

The PCN, which was first established in Burnaby in March 2019 through funding from the province, saw the need for services in the city rapidly accelerate with the onset of the pandemic—and the team says the work it’s been doing here can become a blueprint for other municipalities that want to do primary care differently.

“At the core of our Burnaby PCN is our focus on both the health and wellness of our residents, and our goal of supporting residents—those with family doctors and those currently without—to stay as healthy as possible in their own communities,” said Georgia Bekiou, executive director of the Burnaby Divisions of Family Practice and PCN steering committee co-chair, in an email to the Beacon.

“This whole personal approach has driven us to restructure how primary care medical services are being delivered in our community and to pull these medical services into alignment with the work of our social support agencies that focus on the social determinants of health (such as food security and housing).”

In a talk hosted by UBC’s Department of Family Medicine last week, members of the team, including Burnaby Divisions of Family Practice board chair Dr Birinder Narang, told attendees that the real success of the PCN model comes from its “deep connection and participation” in the community itself—in this case, Burnaby.

Burnaby has three PCNs at the moment, centred around three of the city’s town centres: Metrotown, Edmonds, and Hastings-Brentwood. And Narang said at the talk that each of those PCNs elects local leadership tables that advocate for each of those hubs based on their individual requirements.

“So we wouldn’t expect [the] Edmonds, Metrotown, or Lougheed [communities] to have all the same requirements of our service plan. And our requests for funding and delivery came based on a local needs assessment,” he said.

The network operates different social groups for seniors in each community, for example. In Metrotown, it ran a digital literacy campaign last spring, and in Hastings-Brentwood, it’s running a program helping low-income people access and store government IDs.

The PCN also allows physicians to connect patients directly with other services they might need through the people already doing that work in the city.

“The key is to pull all of those providers into a single team around a patient so we can deliver holistic care. So [it’s] a very lofty and ambitious, patient-centered goal for our community,” Bekiou said last week.

Narang said at the UBC-hosted talk that the PCN model offers a unique chance to integrate care and wellness.

“The way I see us as family physicians—we are bridges inherently in that space, by the nature of our work that we do. And so the PCN aligns with my own personal vision of what medicine should be, which is why I’m so involved with it,” he said.

The team has created several working groups with grassroots community-based services to discuss how best to meet the needs of Burnaby residents—and when the pandemic hit, the team saw the need for many of those services explode overnight.

The food security working group, for instance, saw the number of families accessing the Burnaby food hub go from 2,000 families a week to 6,000 families a week. It also opened several community fridges to make sure that those in need could access food supplies in as low-barrier a way as possible.

“Support for substance use and the opioid crisis is happening through these same channels, and with direct ties and PCN support from the Burnaby Peer Network,” Bekiou said.

“With the involvement of the peers and support of Burnaby Neighbourhood House and other agencies, the PCN has driven the development of a Dudes Club here, which will focus on supporting men in our community where we know that substance use and the opioid crisis are most critically displayed.”

Some of the work, Narang said during the talk, happened in more informal ways. At the onset of the pandemic, for instance, he and his peers would go out to shelters and Progressive Housing Society on their weekends and offer advice for anyone who needed it on COVID, substance use treatment, and housing. Sometimes, they would set up things like food deliveries and hygiene supplies.

The PCN team feels very passionately that the way they’re doing things is a different, and refreshing, approach to primary care—one that more acutely senses and responds to the needs of its patients.

A traditional primary care model has the unfortunate result of excluding some patients, Bekiou told the Beacon. That group of people includes those who face many systemic barriers to accessing healthcare, like people experiencing homelessness, newcomers to the community, or homebound seniors.

But it also includes people who simply can’t access a family doctor—which, in 2019, was as many as one in six Burnaby residents.

The PCN, includes about 160 full scope family doctors operating out of 60 clinics across Burnaby—but Bekiou said what sets this model apart is that they connect the practices and clinics together, making it easier for physicians to provide more service hours to both patients who do and don’t have a family doctor.

It’s also involved in operating the Edmonds Urgent and Primary Care Centre, which opened in September 2019 as the only family-physician-led and -run UPCC in the province.

BC already operates PCNs in several communities across the province, like Mission Fraser Northwest (which encapsulates New Westminster and the Tri-Cities), and the South Okanagan. And it’s looking to expand to more areas.

The team is convinced, after their work over the past few years, that this is a model that can and should be adapted for other cities and regions.

“We have a working example that this works. It requires purpose design and collective passion and commitment among partners to support our communities’ health and wellness. The way that we have been able to partner in Burnaby didn’t happen by accident; it was by design,” Bekiou said.

“The pandemic put our process to an early test and also accelerated it immensely. But we have a blueprint, and it works. And Burnaby is the perfect size—the Goldilocks theory—not too big, not too small, demographically extremely diverse, so that larger and small communities can use essentially the same process. They need a true commitment to partnership, and a willingness to put what’s right for the community first and foremost.”