As clinical care becomes more complex, providing patient-centred care relies increasingly on coordinated interdisciplinary teamwork. Aiming to maintain a stable culture focused on longitudinal, relationship-based care, the Fairmont Family Practice in Vancouver is an interdisciplinary clinic operating under a population-based funding model. This model enables the practice to work with eight physicians, two nurse practitioners, two visiting psychiatrists, and a nutritionist.

The providers work as a team to plan each patient’s care and to share responsibility for all of their primary care needs. To ensure seamless care within the practice, doctors treating colleagues’ patients share detailed notes using their EMR system.

“Team communications is key to providing our patients with the best care,” says Dr Brenda Hardie. “Our patients know that their care is coordinated —because their providers are connected.”

“Because we are aware of the patient’s health history and needs, we can see each other’s patients as needed,” adds Dr Kuljit Sajjan.

This collaborative approach has created an effective team that shares responsibilities including urgent care, extended hours, and longitudinal care. To enable responsive care in the clinic, many doctors reserve some same day appointments, and each takes a turn being the “doctor of the day” who has no scheduled appointments and is available to patients with immediate care needs.

“This gives our patients the support they need in our clinic,” says Dr Sajjan. “They don’t need to seek care in other settings like a walk-in or ER, where providers unfamiliar with their history may order duplicate labs or cause other unnecessary delays in the system.”

The practice is also dedicated to maintaining patient attachment outside regular hours through:

  • Extended hours: Doctors take turns opening the clinic on Saturdays.
  • Rotating on-call duties: During off hours, the practice’s answering service directs patients to call services at BC Women’s and Children’s Hospitals, connecting them with the practice’s on-call doctor to determine the best way to manage care. This may involve providing patient advice over the phone, opening the clinic outside of scheduled hours, or making a home visit.

The team is not only committed to their patients, they take care of each other by covering time off for parental responsibilities and professional training.

“It really matters that our practice has a strong sense of community —extending to our patients and each other,” says Dr Hardie.