Rural Coordination Centre of BC2018-19 Year End Report
Foreword from our Executive Directors

The work of the RCCbc is driven by a desire to improve the health of rural patients in our rural communities. This is one of the principal reasons that we, the RCCbc as a network of passionate physicians and team members, do the work we do.

The Rural Coordination Centre of BC (RCCbc) is embarking on its 12th year of operations. During the past years, we have grown tremendously, all while maintaining our mission: to help improve healthcare service delivery for British Columbia’s rural citizens; to support the medical practices and overall well-being of BC rural health service providers; and, to foster an interest in and uptake of rural medical education throughout the spectrum of learning and practice, from high schoolers to semi-retired locums.

In 2018-19, RCCbc – working at the behest of the Joint Standing Committee on Rural Issues (JSC) – took on the coordination of several new initiatives, several of which are outlined in this Year End Report. We’ve also been invited to participate at in key current discussions regarding the Patient Medical Home and establishment of Primary Care Networks, bringing a rural perspective to the table and creating space for more rural voices to be heard as we all collectively shape the future of healthcare service delivery in this province. We are also continuing to carry the momentum forward on the many successful projects such as the Nanaimo Emergency Education Program (NEEP), the CARE (Comprehensive Approaches to Rural Emergencies) Course, and the Rural Site Visits Project.

While all of this work is important, for the 2018-19 report, we are choosing to focus on a few select stories that demonstrate the power of relationships to facilitate innovation and collaboration. We believe that relationships are the foundation on which we can do good work. The RCCbc facilitates and coordinates many of the activities of rural innovators, while the JSC funds initiatives and adjusts policies to reflect modern rural medicine. The bulk of this work is carried out, and driven forward by several networks (both formal and informal) that include: rural and regional physicians; the Divisions of Family Practice; UBC Rural Continuing Professional Development (RCPD); UBC Department of Family Practice (along with other various groups within the Faculty of Medicine); health authorities; BC College of Family Practice; the Joint Collaborative Committees; the BC Rural Health Network; and, the Ministry of Health. All of these organizations gather together to work on ways to improve, sustain, and transform our rural healthcare system to better serve rural populations. Without these relationships, rural healthcare would be more fragmented and potentially more fragile. Those of you who have sat at RCCbc’s tables have heard us start or end a meeting with the statement “this [work] is all about relationships” – this truth is more evident than ever before as we strive to establish collaborative networks and connect with other health organizations throughout the province.

We invite you to learn how RCCbc is centering relationships and collaboration at the core of its work. We hope that these stories inspire you to reach out and join with others, or to form your own network, leveraging the power of your relationships to transform your communities.

Dr. Ray Markham and Leslie Carty

Executive Directors

Report from the Rural Doctors' UBC Chair in Rural Health

Dr. David Snadden was appointed to the Rural Doctors’ UBC Chair in Rural Health in 2016. Over the last two years, his efforts to grow rural-based research, rural advocacy and rural mentorship have strengthened the UBC Faculty of Medicine’s partnership with the Joint Standing Committee on Rural Issues (JSC) and the Rural Coordination Centre of BC (RCCbc), as well as with health professionals and other universities across the province.

Dr. Snadden is a member of a number of research teams that were successful in securing grant funding throughout 2018 for major projects to guide improved health care in rural communities. In collaboration with a large interprovincial partnership team he is exploring the early career choices of new family physicians and is a co-investigator in a group examining Northern Health’s primary care reforms. In addition he works with a large group developing an hermeneutic approach to implementation science and supports a project exploring humanities based approaches to culturally safe healthcare in northern BC. He also assists the Rural Site Visits Project (see story below), visiting sites across rural BC to interview health professionals and Indigenous communities and helping shape the project’s ethics process, research design and data analysis strategies. He has provided advice to an Australian group to develop advice on re-shaping General Practice training in Australia. As part of this work he has published several articles in international journals.

Dr. Snadden serves on numerous committees, providing leadership and guidance around rural care at the national and provincial levels. He sits on the Rural Road Map Implementation Committee, a collaboration between with the College of Family Physicians of Canada and the Society of Rural Physicians of Canada that advocates for improved support for rural health care providers.  He is on the Northern Quality Improvement and Research Conference Advisory Committee, and he is a member of the Rural Coordination Centre of BC‘s Core and Leadership Advisory groups. Dr. Snadden also serves the international community as an academic reviewer for several journals: CMAJ Open, Medical Teacher, Academic Medicine, Remote and Rural Health and The Postgraduate Medical Education Journal. He was invited to attend a 2018 Northern Health Executive meeting along with the CEO, Board Chair and Clinical Director of the Western Australia Health Authority.

Dr. Snadden continues to guide conversations about the evolution of rural care. Last June, he was invited to speak to care providers in Nunavut about the emerging models of primary care delivery in rural areas and the impacts of generational change. He also presented on the recruitment and retention in the rural practice context of Generational Change, during a series of research meetings at the Northern Health Innovations Commons. Training opportunities for health care professionals like this are ongoing and translate the best practices that are most current with up-to-date rural care literature. This year, Dr. Snadden also participated in the Provincial Healthcare Partners’ Planning Retreat (see story below), bringing an academic perspective to the partnership of health, academic, government, community and linked contributors/organisations to discuss ways of facilitating system change in rural health. He continues to advise physicians interested in rural research through the RCCbc Northern Node and its support team, to vet rural research applications, to the RCCbc research program and to supervise three rural research fellows all initiatives supported by the JSC to build capacity for research in Rural BC.

For his efforts to elevate health in the region, Dr. Snadden was recently inducted into the Northern Medical Society Hall of Fame. We remain grateful to the JSC on Rural Affairs and the RCCbc whose generous support of Dr. Snadden’s leadership is transforming health for everyone.

A wide array of individuals and organizations were invited to contribute their thoughts, experiences and ideas on how to best enable “changes that lead to improved patient and community health outcomes.”

At the end of 2018, RCCbc was presented with the opportunity to host a meeting in collaboration with BC’s Joint Collaborative Committees (JCCs), the General Practice Services Committee (GPSC), and the First Nations Health Authority (FNHA) to discuss primary healthcare networks within a rural context. What could have been another meeting among a handful of representatives from these individual groups evolved into a dynamic, inclusive, and inspiring Provincial Health Care Partners’ Planning Retreat that was held in Vancouver from Jan 27-29, 2019.

A wide array of individuals and organizations were invited to contribute their thoughts, experiences and ideas – through the use of an Appreciative Inquiry (AI) process – on how to best enable “changes that lead to improved patient and community health outcomes.” Using the health partners framework (see figure below) as a guide, representatives from academia, health authorities, industry, rural communities, and government joined family physicians, specialists, nurses, and other health care providers gathered together to determine how to collectively enact this healthcare system transformation.

Figure 1. The Healthcare Partners Framework for collaboration, based on the Partnership Pentagram developed by WHO with a modification to include industries with a strong stake in healthcare systems

The retreat process featured alternating rounds of dialogue and deliberation within Peer Groups and Partner Groups, following the four stages of Appreciative Inquiry – Describe, Dream, Design, Deliver. Peer Groups were comprised of individuals from the same health care stakeholder sector while Partner Groups were comprised of individuals coming from different health care stakeholder sectors. This engagement approach encouraged consensus building around individual and collaborative future actions and commitments to improve and innovate BC’s healthcare system. All future actions and commitments were collected in a Living Strategic Framework – a dynamic document that will incorporate improvements, learnings and refinements over time – that is structured around four pre-established strategic priorities:

  1. co-creating culturally safe and humble primary health care;
  2. designing, planning for and implementing Team-Based Care;
  3. increasing citizen and community involvement in health care transformation processes; and,
  4. improving access and transitions for patients in rural and remote communities.

The Health Care Leaders’ Planning Retreat was an important moment in the history of health care design and delivery in British Columbia. “It fostered new and existing relationships and allowed folks the opportunity to discuss health care planning in a collaborative way that included many perspectives and voices,” observes RCCbc Networks Director, Kim Williams. “The retreat has become the foundation for ongoing partnerships and has allowed us to find new ways of working together towards common goals and initiatives.”

A final summary report from the retreat is now available – this document includes the first iteration of the Living Strategic Framework.

To hear the thoughts and impressions of retreat attendees, view the video below. Shorter individual clips are also available on RCCbc’s YouTube channel.

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“Developing patient-centred care models that provide the right care in the right place at the right time, while supporting rural family physicians and generalist rural specialists”[1] is the goal of the enhanced RSON networks

Report by Paul Kendal, Project Coordinator for RSON

RCCbc’s Rural Surgical and Obstetrical Networks initiative (RSON) was rolled out into five rural communities in 2018/19, the culmination of years of engagement. The RSON team, led by Kim Williams and Dr. Nancy Humber and supported by project coordinator Paul Kendal, worked closely with the Interior Health (IH) Surgical Network team to engage with the five potential RSON sites on the shape and direction of their maternity and surgical programs through spring and summer 2018, in order to begin RSON operations in the fall. The timing for this engagement was auspicious, as surgical expansion funding was made available from the Ministry of Health, allowing IH and its communities to leverage the two sources of funding into comprehensive plans for surgical and maternity expansion. The relationships developed between RCCbc, IH admin, and staff at the IH sites was foundational to the success of this work.

Five sites in Interior Health meet RSON’s criteria, being small surgical sites staffed by GPs with Enhanced Surgical Skills (GP ESS) or a solo General Surgeon: Creston, Fernie, Golden, Lillooet, and Revelstoke. In just a few months of expanded capacity, these sites increased their surgical day care volumes by 21% and endoscopy volumes by 79%, for an overall volume increase of 61%. This year over 1,300 additional patients received safe and appropriate surgical and maternity care in the appropriate location thanks to this joint surgical expansion. RSON also funds overnight nurse call and call-back time to support the maternity programs at four sites, and has supported the opening of a maternity clinic at a fifth.

RSON is the BC implementation of the recommendations of the Joint Position Paper on Rural Surgery and Operational Delivery (2015), which recommends that small surgical sites be integrated in robust networks with their regional referral sites. This aligns directly with the philosophy and Actions of Direction 3 of the Rural Roadmap resulting from the work of the Advancing Rural Family Medicine Taskforce. These documents are representative of the move within rural health planning and policy to focus on the key role that personal and professional networks occupies in rural regional networks. “Developing patient-centred care models that provide the right care in the right place at the right time, while supporting rural family physicians and generalist rural specialists”[1] is the goal of the enhanced RSON networks, in specific reference to Actions 11-13 and 15.

The value of this relationships-based approach can be clearly seen by looking at the RSON roll-out at Elk Valley Hospital (EVH) in Fernie. Fernie is a town of 5,000 in the Rockies, that along with the rest of the East Kootenays refers primarily to East Kootenay Regional Hospital (EKRH) in Cranbrook. The community is supported by very active Facility Engagement and Division of Family Practice teams.

It became clear in the RSON engagement sessions that relationships between EVH and EKRH were improving as joint planning for surgical expansion was taking place. The RSON narrative report from EVH to RCCbc directly supported this. “I believe that the most important success to this project for us has been the improved engagement it has brought to our staff at this site and the physicians and with the team from our Regional Centre at EKRH,” said the report. “Relationships have been strained in the past and now show a remarkable improvement.” EVH set up a Visiting Specialist room on site for the EKRH specialists to do consults and visits. “The visiting specialists have been very pleased with the services that we are providing, as well as the staff here at EVH,” which has operational consequences. “Each of the visiting specialists has provided more bookings at this site and have pre-booked” for 2019/20.

RSON supported a staffing increase at EVH to facilitate this surgical expansion, timely due to the recent recruitment of a GP ESS to the community. OR Nurse, OR Medical Device Reprocessing, OR Housekeeping, and OR Unit Clerk positions have been filled. The Patient Care Coordinator roles have been increased to provide 7-day support for maternity care. The additional nursing roles help provide on-call coverage at the site, which has reduced weekend closures and will lead to the site being open 24/7. “Adding the support in the OR has also increased the efficiency, increased the volume of procedures.” This expansion jumps off the page of the volume report, with surgical day care cases increasing by 58% and endoscopy by 150%. “The nurses are now able to focus on patient care to improve the quality of care provided.”

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[1] Advancing Rural Family Medicine: The Canadian Collaborative Taskforce, 2017. The Rural Road Map for Action

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…several participants noted that an Indigenous Physicians Network would reduce isolation and provide collegiality, and also serve as a focus for Indigenous Physicians to take collective action on important issues…

This year, RCCbc took a major step forward towards forming an Indigenous Physician Network in British Columbia. Dr. Terri Aldred, Indigenous Health Lead for RCCbc, explored the value and appetite for forming such a network by reaching out to: the national Indigenous Physicians Association of Canada (IPAC); the First Nations Health Authority (FNHA); Indigenous leaders, residents, and medical students at UBC’s Faculty of Medicine; elders; and, select allies. Working collaboratively with all of these partners, Dr. Aldred and RCCbc Program Coordinator Kassia Skolski formed a committee to discuss how to best collect a wide range of views, information, and feedback about the desirability of an Indigenous Physician Network in BC. The group quickly agreed to host a three day gathering that would allow for collective learning and discussion as well as provide opportunities for mentorship and leadership development.

Traditional Indigenous knowledge, practice, and celebration were incorporated into the agenda throughout the weekend, along with a presentation on anti-racism, and an interactive Q+A panel with practicing Indigenous physicians. One participant commented that they liked “the mix of student-only [spaces], cultural teachings, elder connecting, and student and physician shared perspectives,” and many participants were in favour of hosting this type of gathering again, possibly “at different sites” so that a wider variety of people could participate in the event. The energy of the room overall was high, positive, and forward looking.

During the small group work, several participants noted that an Indigenous Physicians Network would reduce isolation and provide collegiality, and also serve as a focus for Indigenous Physicians to take collective action on important issues, such as advocating for better health service delivery for underserved Indigenous populations, and supporting health science mentoring opportunities for young Indigenous learners. One participant suggested that what was needed was “creative disruption [and an exploration of] how [to] build relationships and/or a community of practice to decolonize medicine.”

Most participants left with a sense of excitement and anticipation for the future, along with the knowledge that this “is hard work (emotionally, mentally and spiritually) [but also] we are part of a community that supports one another.” The planning committee convened by Dr. Aldred collected the visioning notes generated during the small group discussions at the Indigenous Leadership and Mentorship Symposium and will sift through the valuable feedback to help shape Indigenous physician leadership and mentorship going forward.

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We want PRA-BC candidates with the right skill set to be placed in a community that is right for them. The hope is that a good match will yield high quality healthcare services, and will result in the retention of the physician in community.

With the success of the Practice Ready Assessment BC (PRA-BC) program, there is a growing recognition that preparing this stream of physicians for rural medical practice requires more than clinical education supports. PRA-BC candidates – like all rural physicians – must navigate multiple processes when joining a health authority/clinical practice/hospital, in addition to discovering how to access mentor and peer supports – all while settling themselves and their families into a new environment. In 2018-19, several new projects were initiated as part of the “Setting Up for Success Initiative,” an ongoing multi-pronged strategy that provides PRA-BC candidates with collegial, educational, and administrative supports as they transition into rural medical practice. These new projects were developed through the collaboration of RCCbc with UBC Rural CPD (RCPD), Rural Education Action Plan (REAP), the CODI app team, the Nanaimo Emergency Education Program (NEEP) program, and the PRA-BC administrative team, with an eye to building more resource infrastructure for new-to-practice rural physicians as well as reducing administrative duplication and complexity where possible.

Over the past year, RCCbc successfully petitioned the Joint Standing Committee (JSC) for funds to launch four new projects as part of the “Setting Up for Success” Initiative. These projects are additional to existing supports for PRA-BC candidates and new to rural practice physicians, which include Learning Plans developed for individual physicians by UBC RCPD, and access to NEEP which provides remunerated fellowships in rural emergency medicine training. (Scroll down to read our story on NEEP)

Evaluation of the PRA-BC program – past cohorts of PRA-BC participants were interviewed using an Appreciative Inquiry (AI) process and asked to assess the program, specifically what is working and what might be improved in terms of content, training delivery, and deployment. The results of the evaluation will be utilized by the PRA-BC steering committee to tailor the program to better meet the needs of future participants as well as rural BC communities receiving these physicians. “Our aim is to facilitate the best match possible between PRA-BC candidates, the rural communities, and the health authorities,” says Dr. Dietrich Furstenburg, a member of the PRA-BC steering committee. “We want PRA-BC candidates with the right skill set to be placed in a community that is right for them. The hope is that a good match will yield high quality healthcare services, and will result in the retention of the physician in community.”

Enhancing peer coaching supports – additional funding was provided by the JSC to increase capacity of UBC RCPD to offer coaching and mentoring supports for new-to-rural-practice physicians, including PRA-BC candidates. The Rural Physician Mentoring Program is now available upon request to any and all physicians entering rural practice in BC. Additional seats in the Clinical Coaching for Excellence Program were funded, and additional coaches trained, to provide supports for physicians looking to improve their rural FP anesthesia and emergency medicine skills and practices. UBC RCPD also expanded the number of positions available within its Coaching and Mentoring Program (CAMP)  for PRA-BC physicians, allowing these providers to look for supportive relationships from a coach or mentor who can help them meet their learning needs. “[UBC Rural CPD, RCCbc, REAP, and the JSC] are here to help identify gaps and learning needs, and to set up CME/CPD that can help fill those gaps and meet those needs,” says Dr. Bob Bluman, Acting Associate Dean and Executive Medical Director for UBC CPD. “We want to connect with physicians going into rural practice who are looking for supports to help them transition and settle into the community.” Doing so not only smooths the transitions for both provider and community, but potentially increases the chances for retention of PRA-BC physicians and their families once the Return of Service is completed.

CODI App development – Drs. Don Burke and John Pawlovich along with developers Jeff Harder and Dave Loewen, developed an innovative person-focused, relationship-based app that enables all rural providers, including PRA-BC physicians, to instantly connect with a trusted intensivist colleague via a mobile device to seek advice and/or a second opinion during an emergency case. In addition to providing an instant connection on a familiar device, it also allows orders to be dictated and inserted into the patient’s medical chart after the call ends, and consults may be claimed for CME/CPD learning credits by the rural provider.

CODI is one of several virtual in-time tools available and/or being developed to support rural physicians in the rural ED. For more details on this app, scroll down further to read our story about CODI.

Coordination of Onboarding processes – “Onboarding” is a process initiated by health authorities to orient, credential, and integrate new physicians working – in part or in whole – at a health authority facility. The process involves multiple aspects and can be complex to manage (see Northern Health example, below).

RCCbc is meeting with multiple health authorities to discuss “rural-proofing” the onboarding process by including cultural safety and humility training for new-to-practice rural physicians as well as a “culture of medicine in rural BC” component that introduces skills such as team-based care communication. RCCbc has also secured funding from the JSC to support a working group in each Health Authority – the intent is to focus on meeting the needs of both physician and organization by working through onboarding processes and seeing where there might be potential for alignment and/or coordination of activities.

RCCbc and Northern Health have begun to work together to assess the health authority’s onboarding process. Dr. Dietrich Furstenburg, who participates on the Northern Health committee overseeing the Onboarding Process, observed that the health authority’s goal is to develop a global process for bringing new physicians into the fold. “Developing a global process will involve a lot of relationship building between Northern Health and the private-run clinics which have their own onboarding processes. These relationships are critical as we want PRA-BC candidates to know what to expect, and to feel that they will be well looked after when they arrive in community.”

RCCbc is currently engaged in discussions with Interior Health and Vancouver Coastal Health to determine whether there is interest in collaborating on this work.

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…past NEEP participants were positive about the impact of the program on their lives and their practices, with one Fellow summarizing the difference as: “my competency and [comfort] in emerg increased, my confidence increased tremendously.”

The Nanaimo Emergency Education Program (NEEP) is a popular three month Emergency Medicine fellowship for family physicians practicing full-time in rural communities in BC. Designed by Nanaimo physician Dr. Kevin McMeel and supported by RCCbc, Rural Education Action Plan (REAP) and the Joint Standing Committee on Rural Issues (JSC), this program is taught by emergency room physicians at Nanaimo Regional General Hospital (NRGH) and provides both academic sessions, simulation training, and high-volume, varied, hands-on learning. One of the most attractive features of the program is that it allows Fellows to flexibly schedule their training so that NEEP training can be synced with existing rural community practice commitments. Fellows also voiced their appreciation for the ability to customize NEEP training content (including options such as anesthesia, intensive care, rural emergency, point-of-care ultrasound) to meet individual learning goals.

The flexibility and utility of NEEP has led to a high demand for this program from across the province, with providers and health authorities looking at the program as a potential tool for supporting new to practice rural physicians during their transition to rural community BC medicine. To assess whether NEEP should be scaled up, and if so, how to best approach this task, RCCbc is evaluating the program to identify opportunities for improvement, and to learn about the impacts of the program after completion. A summary of this evaluation follows below.

Overall, past NEEP participants were positive about the impact of the program on their lives and their practices, with one Fellow summarizing the difference as: “my competency and [comfort] in emerg increased, my confidence increased tremendously.” In addition to boosting individual education, competence, and confidence, Fellows are returning to their communities and sharing their learnings with colleagues and learners.

NEEP is in the process of applying for accreditation with UBC CPD, and is examining the possibility of offering individual CME tracking for participants. It has also been approved for continued funding by the JSC and for expansion into two additional regional sites – one in Interior Health and one in Northern Health. Dr. McMeel, RCCbc, UBC CPD, and REAP are working with Northern Health and Interior Health to determine the best path to take in each region to facilitate this expansion – soon, many of BC’s rural physicians will have access to this incredible program, closer to home.

NEEP evaluation

adapted from a report by Adrienne Peltonen, Research and Evaluation Coordinator, RCCbc

As part of the evaluation process, NEEP Fellows were interviewed after completing the program and asked to identify the impacts and value of the program to their practice. Overall, comments were positive, with the impacts most commonly described as:

  • increased confidence in the emergency room and increased comfort performing procedures
  • improved skills in ultrasound
  • pursuing further professional development to develop more advanced skills (e.g, ultrasound or EM certification)
  • teaching and sharing learnings with colleagues and learners
  • initiating new initiatives in the emergency department (e.g., simulation programs, journal clubs, rounds, etc.)

The Emergency Room Physicians (ERPs) at NRGH interviewed for the evaluation were overall positive and supportive, stating they enjoyed teaching and experienced positive impacts from teaching. It was noted that taking on this role required additional work, and at times impacted billing and flow in the ED.

Areas for improvement identified by participants included:

  • providing additional content in the areas of trauma, level 1 patients, EKG, and pediatrics
  • streamlining remuneration
  • tailoring content for already practicing rural physicians
  • providing access to experiences and volume to meet Fellows’ learning objectives
  • improving program accessibility for physicians with established rural practices
  • developing options for increased supports for ERPs
  • offering videoconferencing for the academic sessions
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The app is the medium that allows the intensivist to support the people in the emergent situation – the [rural] patient and the [rural] provider – by focusing on what Dr. John Pawlovich succinctly describes as “how can we help you where you are in the moment?”

Technology and virtual supports are increasingly being deployed in rural primary care practices to support physicians working in rural and remote communities. Video technology, online searchable reference materials, and phone-based supports are just some of the tools being used in rural settings, with consultations evolving to the point where local patients are now able to stay in community for select specialist visits. This ‘closer-to-home’ care reduces both costs and risks of distant travel for the patient as well as associated family and economic disruptions resulting from, say, a three week trip to a larger centre to facilitate a birth.

Left to right: Jeff Harder, Dr. Don Burke, Dr. John Pawlovich, and Dave Loewen

The next wave of technology being explored and developed focuses on providing physicians and nurses with virtual real-time supports. The Joint Standing Committee on Rural Issues (JSC) provided seed funding for one such tool in 2018: the CODI (Critical Outreach and Diagnostic Intervention) app, which was conceptualized by Drs. Don Burke and John Pawlovich and brought to fruition by software developers Jeff Harder and Dave Loewen. Technologically, CODI facilitates direct connections between rural physicians and regional/urban specialists to consult on challenging cases that present in rural emergency departments. However, as Dr. Pawlovich notes, “this is a human story, not a technological one. The technology supports people and relationships, it doesn’t define them.”

Described as “an intensivist in your pocket,” the app functions similarly to a FaceTime call, allowing colleagues to discuss the case face-to-face, and to view the patient through smartphone video. At the end of the call, summaries/instructions can be dictated and transcribed through the app, so that medical reports flow back to the rural physician in a timely fashion for integration into the patient’s chart.

The true benefit of CODI however, is the recruitment of supportive, compassionate, rural-aware intensivists who understand the challenges and anxieties faced by rural physicians and nurses in what can often be a low-resource setting. The selection of physicians who understand the rural healthcare context and can provide appropriate supports, advice, and/or a second opinion to their rural colleagues on-demand has allowed the app to be adopted eagerly by a wide range of rural emergency medicine providers. Feedback from Dr. Rosenberg on Pender Island summed up several users’ experiences: “I was very happy to have a button to push and someone to consult with as being able to talk to someone is SO reassuring. No matter how many [critical care] courses I do, the first presentation of each emergency diagnosis gets my heart racing.” The app is the medium that allows the intensivist to support the people in the emergent situation – the patient and the provider – by focusing on what Dr. Pawlovich succinctly describes as “how can we help you where you are in the moment?”

Drs. Burke and Pawlovich intended for CODI to be one of ways in which technology and people can help address inequity in healthcare service delivery in BC. Although there are technologies which are offering simple healthcare consultations for rural patients, it is the thoughtful integration of real time support where it matters the most that is supporting in-community providers address their very real challenges and anxieties. Drs. Burke and Pawlovich have observed that through a tool such as CODI, “anxiety is lessened, physicians and nurses are empowered, and most importantly, patients gain an exceptional level of care closer to home.”

The future of CODI is bright as it evolves. Through a partnership with UBC CPD, consults occurring through the app now qualify for CME/CPD credits. REAP and RCCbc, along with the JSC, were initial supporters of the CODI app development project. Recently, the CODI team partnered with the Northern Interior Rural Division of Family Practice (NIRD) to promote and disseminate the app amongst northern BC rural physicians, and has strengthened its relationships with all health authorities, including the Provincial Health Services Authority and the First Nations Health Authority. Lastly, but not least,  true to the adage that “a rising tide floats all boats,” the successful uptake of CODI by rural physicians, locums, and nursing stations, has paved the way for other innovators to explore other virtual in-time emergency medicine supports for healthcare providers throughout the province.

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Site Visits team members are successfully establishing relationships with community health partners such as the Divisions of Family Practice, the regional health authorities, and local First Nations band offices during their visits. The teams are working to increase community awareness of supports and programs offered by RCCbc and the JSC, make connections to key contacts, and open communications channels within the community between groups.

2018-19 was a year of growth for the Rural Site Visits Project, as new Project Coordinator Krystal Wong settled into her role overseeing the administrative details of this three year Joint Standing Committee on Rural Issues (JSC) initiative. Several physician consultants from RCCbc’s Core team were recruited and trained to become Site Visitors, and three additional RCCbc staff – Erika Belanger, Ashley Medwid and Jordan Christmas – were trained to support the teams during visits, allowing the project to scale up the frequency of travel to BC’s rural communities. At the end of May 2019, the project had visited 60 communities and hosted 207 meetings with community health partners across the province.

Site Visits team members are successfully establishing relationships with community health partners such as the Divisions of Family Practice, the regional health authorities, and local First Nations band offices during their visits. The teams are working to increase community awareness of supports and programs offered by RCCbc and the JSC, make connections to key contacts, and open communications channels within the community between groups. This project has been well received by community members as they appreciate the face-to-face outreach and efforts to get to know their communities.

One notable partnership undertaken by the Rural Site Visits Project is the connection with Northern Interior Rural Division of Family Practice (NIRD) to engage select northern communities. Both groups are interested in learning what’s working well in health service delivery and are mutually interested in identifying where best supports might be offered to these northern rural communities. By combining efforts and sharing information, both NIRD and RCCbc will be able to engage meaningfully without duplicating effort, or overextending and overburdening the rural communities, physicians or staff involved in these outreach initiatives.

Although outreach is the primary focus of the Rural Site Visits Project, the team is also collecting qualitative data from the communities to help identify current challenges, strengths and innovations in local healthcare service delivery. Research Associate Erika Belanger is collating, analyzing, and assigning themes to this data, using it to inform a bi-annual report to the communities visited that summarizes at a high level, common emergent themes from the discussions. These reports also highlight innovations and solutions undertaken by individual rural communities in order to disseminate and foster shared learnings. The first Community Feedback Report was distributed this winter and identified transportation, support, and population as the three most common themes for all communities visited to date. This information will be used by the JSC to better inform the development of its rural healthcare policy and projects to improve health service delivery in rural BC.

Although the Rural Site Visits Project has only been active for approximately a year, Dr. Stuart Johnston, physician lead for the initiative, notes “the extensive feedback from all of the community partners has illuminated many of the strengths and gaps facing rural health care services in BC currently.”

Of interest, the scope of this JSC initiative appears to be unique internationally following an early literature search and discussions with ACRRM (Australian College of Rural and Remote Medicine) attendees at the 2017 WONCA conference in Australia.

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…the primary work of staff at both nodes will be building and supporting local and regional rural healthcare research capacity per the mandate of the Rural Doctors’ UBC Chair in Rural Health, and facilitating engagement for the Rural Site Visits Project.

While both RCCbc and the JSC’s administrative teams have accomplished much over the years, it has long been one of RCCbc’s goals to build additional operational capacity and support engagement outside of the Lower Mainland, to increase rural representation in its work, and to enable “closer-to-home” access to RCCbc resources. In late 2017, RCCbc created and operationalized the first of its rural centers – referred to as a “node” – in northern BC in Prince George. During the 2018-19 fiscal year, the Northern Node found its feet and began working collaboratively with Northern Health and the University of Northern British Columbia (UNBC) – through the Health Research Institute. Over the course of a year, Northern Node staff broadened out both in terms of capacity and activity, adding new staff and new projects to its roster (see report below), as well as engaging local and regional physicians at northern BC CME/CPD events such as the Northern BC Research and Quality Conference, and the Jasper Spring Retreat.

With the Northern Node staff settling into their roles and project work in 2018-19, RCCbc leadership turned its attention to the Interior and began to explore potential collaborations with interior Health as groundwork for establishing a second rural node, this time in Penticton. After determining the best location and most strategic use of resources, RCCbc and Interior Health hired Jason Curran as its new Regional Practice Lead, Research & Knowledge Translation, a role that is shared between the two organizations. Jason will be developing and supporting rural research within Interior Health and will occupy RCCbc’s Interior Node office – located in the new tower at Penticton Regional Hospital – in Summer 2019.

Staff at each individual node are shared between RCCbc and its partners to support various projects; however, the primary work of staff at both nodes will be building and supporting local and regional rural healthcare research capacity per the mandate of the Rural Doctors’ UBC Chair in Rural Health, and facilitating engagement for the Rural Site Visits Project (scroll up for Rural Site Visits Project story). Although the Northern and Interior Nodes focus primarily on supporting local and regional populations, both work with the Vancouver Node to further the work of several province-wide initiatives, such as the Rural Site Visitors Project and the Rural Physician Research Support Grants (scroll down for Rural Grants story).

Northern Node Report – submitted by Janna Olynick and Erika Belanger

The staff of the Northern Node consists of: Research Associate, Janna Olynick who supports the Rural Physicians Research Support Project; Research Associate, Erika Belanger who supports the administrative and research activities associated with the Rural Site Visits Project; and Administrative Assistant, Bree Orser, who supports the UBC Dean’s Advisory Council as well as the Rural Surgery and Obstetrics Networks (scroll up for RSON story). Together they have established a strong presence and point of contact for northern BC rural physicians. The Northern Node also oversees the Health GIS Data Repository and Web-based Portal Project which are both led by Dr. Neil Hanlon in the UNBC Geography program.

In addition to fostering its relationships with Northern Health and UNBC, the Northern Node staff have also built up connections with Doctors of BC, UBC Department of Family Practice, and the Rural Health Services Research Network of BC (RHSRNbc), specifically focusing on the activities of those organizations in northern BC. Northern Node staff are also working with the Northern Medical Program to foster and support an early interest in rural medical research at the undergraduate level.

Janna Olynick observes that for her, one of the biggest rewards over the last year has been helping more than 10 individual northern BC rural physicians select and conduct a research project that is both interesting and impactful. “It’s gratifying to help rural physicians understand the success of their research in terms of supporting rural practice, increasing clinical understanding, and improving healthcare service delivery. I enjoy the challenge of supporting them to do this important work given their very busy schedules.”

Janna also appreciates the power of partnership and how making connections with other rural health advocates and aligning shared priorities allows everyone to improve their function and positively impact rural health service improvements.

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The uptake for both of these grants has been very positive. To date, a total of $198,700 has been distributed to BC rural physician researchers through 17 Rural Physician Research Support Project grants.

Six Rural Global Health Partnership Initiative Grants have been awarded to medical learners and rural physicians, totaling $40,095 in support funds.

In 2018, RCCbc began offering grants to rural physicians and rural-interested medical learners to support research investigations and global health initiatives respectively. The Rural Physician Research Support Project grants offers up to $10,000 per grant to rural physician researchers whose work seeks to advance health in rural BC communities. This initiative is part of the Rural Doctors’ UBC Chair in Rural Health’s commitment to increasing rural research capacity and knowledge within BC’s rural communities.

The Rural Global Health Partnership Initiative (RGHPI) – also launched in 2018 – offers grants of up to $10,000 to foster partnerships between rural BC physicians or medical trainees and lower resource communities in BC, Canada,  and in developing countries. RGHPI seeks to enhance capacity for generalism in rural BC, foster reciprocal learning in diverse health systems  and community contexts, and create innovative solutions to address healthcare equity in rural BC, Canada and globally.

The uptake for both of these grants has been very positive. To date, a total of $198,700 has been distributed to BC rural physician researchers through 17 Rural Physician Research Support Project grants. Research topics range widely from assessing the impact of early school age health interventions (Dr. Onuora Odoh), to evaluating impacts on local health service delivery (Dr. Ella Munro; Dr. Denise Jaworsky; Dr. Floyd Besserer), to measuring environmental impacts on local health (Dr. Michael Slatnik; Dr. Ulrike Meyer). Six Rural Global Health Partnership Initiative Grants have been awarded to medical learners and rural physicians, totaling $40,095 in support funds. Projects from this initiative have included examining contraception uptake and nutritional assessment in rural Kenya, seeking sustainable solutions for menstrual health management in India, and developing a rural medical outreach program partnership between UBC and the University of Namibia.

A list describing several of the funded projects is available here. Or, look up the individual projects in this interactive Google Map:

The work of three recipients of the Rural Physician Research Support Project grant has already been profiled by local BC community newspapers, garnering attention that has raised awareness of the research work and – in two cases – boosted recruitment of people to participate in the individual studies.

Dr. Onuora Odoh’s early intervention oral health education project was covered by Houston Today and provided information about the project to parents and guardians of the K-7 children, including the important fact that study participation is voluntary.

Dr. Paul Dhillon’s project to increase awareness of rural residents’ organ donation status was covered three times by two news outlets (here, here, and here), resulting in a significant uptake of the project by several medical clinics along the Sunshine Coast.

Dr. Ulrike Meyer’s interest in researching the human health effects of unconventional natural gas development (“fracking”) was partially profiled in The Narwhal magazine as part of a human interest feature on environmental health concerns.

Although the Rural Global Health Partnership Initiative projects have not yet garnered local media coverage, RCCbc was pleased to profile UBC medical student Kelsey Furk’s collaboration with long-established community development group Pamoja. Ms. Furk and Pamoja evaluated local knowledge about family planning, and gender-based violence knowledge and services in a rural subsistence farming and fishing community near Kisumu, Kenya. Initial findings were presented at the Western Student and Medical Research Forum in January 2019.

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Click here to see a list of key RCCbc projects and initiatives

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