Richmond Primary Care Networks
What is the Richmond Primary Care Network (PCN)?
Richmond is one of the province’s first cities to adopt the team-based Primary Care Network (PCN) health care model that the B.C. Ministry of Health is rolling out throughout British Columbia. Each PCN is a geographic region with a dedicated clinical team of allied health professionals to support the Family Physicians (FPs) and Nurse Practitioners (NPs) within that region. Richmond residents now have expedited access to MSP-funded care from a wide range of PCN clinicians as a part of their care team. For most services, wait times are up to six weeks. Patients can access these services by referral, or in some cases, these allied health professionals practice within the FP/NP clinic in a co-located arrangement.
Richmond has established three PCNs: PCN 1 (WEST), PCN 2 (CITY CENTRE), and PCN 3 (EAST). These networks allow primary care providers (FPs and NPs) to connect various members of a patient’s care team in a coordinated way so that everyone works together toward the patient’s health goals.
Working together in team-based care allows the members of each team to:
- focus more resources on preventive care
- provide disease management and counselling while arranging for follow-up services in the community
- increase support for patients with complex and chronic health conditions
- leverage their abilities while supporting and relying on each other to provide the best care for patients
- expand Richmond’s capacity to attach patients to a primary care provider (FP or NP)
The B.C. Ministry of Health funds the Richmond Primary Care Network, which is a partnership between the Richmond Division of Family Practice and Vancouver Coastal Health.
Three PCNs in Richmond by Geographic Region
Richmond is made up of many smaller, unique neighbourhoods, each that has its own socioeconomic, cultural, language, and health care needs. Three Primary Care Networks: PCN 1 (WEST), PCN 2 (CITY CENTRE), PCN 3 (EAST) exist to address these needs. SELECT THE WHITE PCN LABEL TABS (RIGHT) to learn more about how Family Physicians (FPs) and Nurse Practitioners (NPs) in each PCN are supported by dedicated teams of MSP-funded health professionals, who are working hard to help patients achieve their health goals. Richmond residents who meet eligibility criteria can meet with their FP or NP to discuss referrals to these PCN services in order to optimize their health.
Team-based Care
Richmond Family Physicians (FPs) and Nurse Practitioners (NPs) are supported within a patient-centred, team-based care network consisting of many different health care providers. This network coordinates the patient care team so that members work together with patient health goals in mind.
FREE ACCESS TO SPECIALIZED SERVICES
Residents of Richmond can now visit their Family Physician (FP) or Nurse Practitioner (NP) to request access to free, MSP-funded services such as care from Clinical Counsellors, Dietitians, Physiotherapists, and more. These health care providers work in a team-based care model that includes the patient and their primary care provider (FP or NP). This free and timely access to coordinated care is leading to improved health outcomes for patients, along with more independence, increased safety, and better access to community services and social supports.
PATIENT-CENTRED, COORDINATED CARE TEAMS
Patients are at the heart of every care team. Based on their health goals, the FP/NP connects their patients with specific health care providers, who then work together as a team and can share observations and recommendations with each other. Patients are involved in and informed about every aspect of their care.
A Richmond FP or NP can invite any of these care providers onto a patient’s care team.
Available PCN Clinician Services
Chronic Disease Management Nurse
- provides support to manage chronic diseases (diabetes, heart failure, high blood pressure, more)
- teaches patients how to understand and develop self-management strategies
Clinical Counsellor
- provides support for anxiety, depression, relationship issues, grief/loss
- helps patients to gain new perspectives
- introduces tools to cope with personal issues
Clinical Pharmacist
- conducts medication assessments
- ensures prescriptions are suitable for each condition
- provides advice on dosage and adverse reactions
Dietitian
- provides nutrition assessment/consultation
- improves patient eating habits
- prevents/delays chronic conditions
- teaches about nutrition needs
- helps patients make sustainable lifestyle changes
Frail Seniors Team
- provides timely, appropriate senior care
- improves overall senior patient health
- increases patient independence
- enhances safety
Occupational Therapist
- helps patients maintain skills for daily activities (personal care/meals)
- teaches adaptive energy conservation skills
- provides stress management strategies
Physiotherapist
- treats musculoskeletal/neurological conditions (arthritis/MSK injuries/stroke/MS/Parkinson’s)
- develops personalized home exercise programs
- helps patients to prevent falls
- provides advice on gait aids
Social Worker
- addresses factors that impact patient health (finances, housing, social supports)
- develops advanced care plans
- provides referals to community programs
Community Link Worker
- supports patient health and wellness goals
- connects patients with social and physical activities
- improves patient physical and emotional wellness
- informs patients about local community services and opportunities for connection
Chronic Disease Group Education
- small, in-person group education
- taught by interdisciplinary Primary Care Network clinicians
- teaches patients and caregivers self-management skills
- classes:
- Type 2 Diabetes
- Pre-Diabetes
- Cholesterol/Dyslipidemia/Heart Health
- Cognition/Brain Health
- Depression/Anxiety
- offered in English, Cantonese, Mandarin (more in development)
- Learn more
Eligibility Criteria
To access the PCN Care Team, patients must meet ALL FIVE criteria:
1. Be a Richmond resident and/or the patient of a Richmond FP or NP.
2. Be a patient of the FP or NP who connects you to your Care Team (i.e. not a walk-in physician).
3. Have valid B.C. Medical Service Plan (MSP) coverage.
4. Not have an active insurance claim related to the recommendation (ICBC, WorkSafe). Referrals will be accepted if the PCN service being referred is not related to the claim. Note: this criteria does not pertain to referrals to the PCN Clinical Pharmacist.
5. Not be in hospital or long-term care.
If you meet ALL FIVE criteria, talk to your FP/NP about being connected with any member of the primary care network care team. If you do not have a primary care provider, visit the Richmond Health Connect Registry to join the wait list for a Richmond FP/NP. For information about the Primary Care Network (PCN) and how the PCN nursing and Care Teams can help, contact us.
Community Link Service
Did you know that social interaction and community connection are great for your health? Richmond’s new Community Link Service connects patients to support services all over the city. The program is designed to boost physical and emotional wellbeing, social connections, and ability to thrive. Family Physicians (FPs) and Nurse Practitioners (NPs) can prescribe a patient visit with the Richmond Community Link Worker, who will identify and connect patients to local supports and services based on their specific needs:
- INFORMATION & SUPPORT related to housing, transportation, income tax, pension, benefits, caregiving, and counselling
- SOCIAL PROGRAMS such as the Friendly Visiting Program, social groups, support groups and language support
- NUTRITION & FOOD PROGRAMS including the Food Bank, grocery shopping, meal delivery, and cooking classes
- PHYSICAL ACTIVITIES through walking groups, fitness classes, and sports activities
You may benefit from the Community Link service if you are:
- experiencing emotional problems and/or major life events (e.g. loss of a spouse)
- living with a chronic disease and a community group program exists that will help you to self-manage (e.g., learn to cook and adopt a healthier diet)
- physically inactive and would benefit from a physical activity group
- struggling with nutrition or food security (e.g. not eating enough food due to financial concerns) and could use support to meet nutritional needs
Eligibility
- You need support for loneliness, isolation, physical health, nutrition, or other services outlined in this section
- You can self-manage with some support
- You are motivated to make changes, address issues, and set goals
- Your Family Physician (FP) or Nurse Practitioner (NP) prescribes this service (i.e. not a walk-in physician)
- You reside in Richmond OR your FP/NP practices in Richmond
Other Considerations
- Your FP/NP should identify the type(s) of support that would benefit your health and wellbeing
- The support must be available within Richmond
Chronic Disease Group Education
The Richmond PCN team offers small, in-person, group education classes on topics that impact a significant patient population. This education and support provides the knowledge and skills for patients and caregivers to better self-manage chronic diseases.
Current Offerings:
- Type 2 Diabetes (English/Cantonese; Mandarin schedule coming soon)
- Pre-Diabetes (English/Cantonese; Mandarin schedule coming soon)
- Cholesterol/Dyslipidemia/Heart Health (English/Cantonese; Mandarin schedule coming soon)
- Cognition/Brain Health (coming soon)
- Depression/Anxiety (coming soon)
Access
Workshops are offered throughout the year based on need, as determined by referrals received. Refer using the PCN Services Referral Form; provide specific requests in the space provided. Patients can also ask their Family Physician or Nurse Practitioner to connect them to these groups.
Explore PCN Careers
If you are interested in joining the Richmond PCN clinical staff, please contact our Recruitment Team to inquire about opportunities.
The Richmond Division supports member physician clinics to recruit family physicians, nurse practitioners, IMGs, MOAs, clinic staff, PCN clinicians, and other health professionals. Job postings, essential information, support and resources, and settlement services are available on our Richmond Health Care Jobs website. Please note, this site is in development and a job search function will be added shortly. Contact our Recruitment Team for more information.
Contact the Primary Care Network (PCN)
The Richmond Primary Care Network team-based approach ensures coordinated patient care, and is designed to support Family Physicians (FPs), Nurse Practitioners (NPs) and their patients. For information or support, call 604-233-5686, fax 604-244-8599 or email us.
