Spotlight on Collaboration

Ruth Dimopoulos is a physiotherapist who would drive a long way to be part of a winning team. For just that reason she commutes 90 km daily from her home in Brockville to Merrickville, Ontario, to work at the Merrickville District Community Health Centre (MDCHC).

"I've found my place in health care," says Ruth who has worked at the Centre for 11 of her 20 years as a health care professional. "The success of this Centre has kept me in the profession. It has been operating long enough to know what it needs to work properly — teamwork — and it has developed entirely in that direction. Since becoming a Community Health Centre (CHC) in 1984, the organization has evolved to the point that it is now a team-building enterprise."

"We hire for relationship building skills, bringing people aboard who are comfortable collaborating with each other. Our rigorous accreditation process also provides a framework for building effective teams and the administration is designed to support this kind of service with appropriate processes and systems. So we now attract that kind of person."

"Of course, the Board of Directors is very supportive, and the Executive Director is an administrator who understands how interdisciplinary collaboration works."

These work arrangements and philosophy are particularly appealing to this physiotherapist. "It means I love coming to work," says Ruth.

"At first I provided the traditional model of physiotherapy treatment but now, because we move to where the need is greatest, I practice long-term management of chronic conditions, health promotion and prevention. I have plenty of scope and play a lead role when it is most appropriate."

Ruth is the Arthritis Team leader. "I offer physiotherapy consultations and do the intake for the program, link the client with needed resources, refer to other providers, manage arthritis resources and co-ordinate the Aqua Flex program."

MDCHC has a catchment area population of about 16,000, the fastest growing part of Leeds/Grenville region. The Centre employs 23 individuals working in full time, part-time and contract positions, a staff complement equivalent to about 14 full time positions.

"I can offer the patient so much more as part of a team," says Ruth. "I work with three physicians, two nurse practitioners, a social worker, a dietitian, a chiropodist, nurses and a full-time health promoter who ensures we're connected with the community. We also work closely with off-site providers such as the Respiratory Therapist/ Asthma Educator, Diabetic Educators, the Occupational Therapist from the Arthritis Society, the local hospital and private practice physiotherapists"

"Our work here is driven by teams, whether it is the primary care team, health promotion team, arthritis team, tobacco team, healthy lifestyle team, organizational committees, or issue-specific work groups."

The Merrickville Centre also ensures that its administrative processes promote teamwork. Work is organized by individual work plans that link with team work plans, and ultimately the strategic directions of the organization. Team meetings and case conferences, along with an open-door policy encourage collaboration.

The Centre uses chart audits to evaluate their work in terms of best practices. Reports are generated using data recorded from client interventions and group sessions. They are improving processes to facilitate internal referrals and are tracking progress with the Balanced Scorecard, a standardized planning and evaluation tool.

The Centre's approach didn't just happen overnight. "Well, to have a team, first you need people. When our complement of providers began to reach critical mass, about four years ago we knew we couldn't just add more cogs to the wheel. We had to start working toward a more collaborative practice."

The re-orientation of the physiotherapy program occurred in 2002 and continues to evolve. A focus on nurse practitioners gave the centre flexibility to accept more clients into the primary health care practice. "All in all, teamwork has meant we can carry a load that is bigger than the sum of our parts, if I can put it that way."

And it wasn't easy. "The most significant barrier was lack of time and limited resources. Developing teamwork requires time and the pressures of waiting lists, a room full of clients and a mountain of charts tend to be the priority of the day. But we managed to dismantle the silos because that's the direction common sense and necessity was taking us."

"In terms of external collaboration, it can be difficult to establish a professional relationship with other organizations or individuals, whether intradisciplinary or interdisciplinary, because resources in many cases are stretched to the limit. In rural areas it can be difficult to find someone where a profession gap exists. "And, of course, funding presents a barrier to filling identified gaps. As well, the fee for service model does not support team work."

But, as Ruth points out, the results are there for the Centre's patients who are now positioned at the hub of a cooperative circle of practitioners. Collaboration provides the patient with the right provider at the right time, with improved access, outcomes and satisfaction. They have an opportunity to participate by making choices and the providers contribute when and where appropriate.

"I recall an arthritis sufferer who came with an exclusive focus on pain and I was part of her awakening to her broader health issues that needed attention, like weight and smoking. With the help of the right providers she has been able to address these issues in an educative way which will not only reduce her pain but will help her live a better life all round — and maybe not so 'round' after all."

As for the professionals, they are learning new perspectives, supporting each other and sharing the responsibility, which reduces the load. "One very positive factor, for sure, is the Community Health Centre model itself which, by its very nature can support and encourages teamwork. Yet I encounter very few health care professionals who have heard much about CHC's. They need to know more about this type of practice, to see the outcomes and to know that the Family Health Team concept is essentially modeled on the CHC."

"Primary care reform will mean more and more providers will have increased awareness, although discussions frequently focus upon nurses, nurse practitioners and physicians. Future health care professionals will definitely require exposure to the Community Health Centre concept of primary health care during their education."

"Referrals are just not enough. In my experience physician referrals have been a one-way process — in other words a prescriptive process. The referral is made and the provider supplies the requested service and is kept at a distance. To be truly collaborative there needs to be an openness to, and opportunity for, dialogue. There can be a number of barriers that prevent this from happening — time, accessibility and the system hierarchy. And, again, fee for service does not easily support collaboration."

Looking ahead Ruth Dimopoulos still wants to keep the change happening and the improvements coming. She wants even more local and regional collaboration within her own discipline — bringing in hospital, home care and private practice physiotherapists to explore opportunities for working together. She'd like to clarify who offers what service and she'd like to conduct peer reviews.

Ruth is clear about what has been achieved to date, though. "This is a very satisfying way to practice. It is win-win for our patients and for us. Burn out is a constant threat to providers and this is a good way to address the issue. An up-front investment of time can ultimately lead to more efficient and effective care and create a more supportive environment for the professional. It fosters learning and growth — and it's stimulating."