Co-Designing Health Care With Community
South Peace region is a rural area of 48,000 people living in three communities as well as rural and remote places. Anchored by Dawson Creek (Mile 0 of the Alaska highway), Chetwynd and Tumbler Ridge, it is on the border with Alberta in BC’s north. The population is about 20% Indigenous, with stunning landscapes, dinosaur fossils and wonderfully friendly people, driven by resource extraction and related industries.
The region has all the health issues you might expect in such a setting, including a shortage of family physicians, limited access to specialist services, and few transportation options for patients who need to travel significant distances to get the care they need.
In 2023, local health partners (Division of Family Practice, Northern Health and FNHA) received funding to participate in the Primary Care Network initiative (PCN). PCN is a provincial project that builds on past experimentation, supported and directed by the Ministry of Health and the Doctors of BC. It provides resources for health system partners to build a plan to supplement health care services with new inter professional teams. The PCN through the Ministry of Health also provides ongoing resources to maintain whatever improvements are achieved.
A New Approach: Co-Designing A Health Care System
The South Peace region was one of the last in the province to develop its PCN, and they decided to do it differently: instead of physicians and health authorities (both experts in health care delivery and systems), the leaders of the PCN decided to co-design the improvements with local agencies, Indigenous and non-Indigenous community members. This inclusive process brought a patient-centred and community wellness focus to the work.
The PCN Steering Committee set up sub-committees in each of the three major communities: Dawson Creek, Chetwynd and Tumbler Ridge. These committees would generate their own plan for their community and the surrounding area and then we would create a regional plan.
This approach had its risks in that every stakeholder in the health care system has their own interest, opinion and experience. One of the ways we mitigated the risk was through governance: a regional Steering Committee that also had broad representation would have ultimate decision-making responsibility.
The Inner State of Collaboration
Coming together, we recognized that physicians, administrators, municipal officials and patients all have different perspectives on what needs to change, different accountabilities and even different ways of talking. Thanks to our Committee chairs , we were able to assess this challenge and structure time in our process to ensure that all participants could bring their full selves to the discussions.
After introductions and a process overview, we switched our focus to the function of the amygdala. The fight, flight, freeze or fawn reaction can inhibit the flow of difficult conversations, constructive conflict and creativity that we needed to bring our best ideas forward, and this can be triggered even by the way we bring ourselves to the conversation.
For example, physicians solve problems quickly, decisively and with a focus on the functions of health care workers that could be added to improve the system of care. The way physicians express their ideas can intimidate or arouse feelings of imposter syndrome in patients, leading them to hold back from contributing.
On the other hand, patients are more likely to tell a story about the treatment that they or a relative experienced when they needed medical attention. The stories usually describe sub-optimal treatment or care, and this can arouse feelings of shame, regret or judgement in the physicians.
To help participants bring their best selves to each meeting, we did brief training in a three step process:
1. Recognizing when our amygdala is taking over. Self-diagnosed signs include boredom, anger, sweaty palms, critical comments designed to shut others down, negative self-talk or feeling like we want to leave the room;
2. Taking action to return to mindfulness. We practiced shifting our focus to the present through tactile, audible or visual cues. We might draw our attention to the face of the speaker with whom we disagree, and focus so much that we notice something new such as a mole or the colour of their eyes. Or we could shift our attention to the feelings of our hands on the table, paying attention to temperature or texture;
3. Call in our best selves. We reminded every participant to consciously call on their highest capacities we have as humans: curiosity, empathy, creativity and the ability to navigate to an imagined future.
The reward: Creative problem-solving
Participants were responsible for monitoring their own state and taking action, and this process can be done without anyone else knowing, because they process is only visible to the person doing it. The result was a process that brought out the best in our participants – more flowing conversations, more vulnerability, and more creativity.
Our creativity included reimagining the human resources that were proposed by our plan. In rural areas, it is often difficult to recruit from outside the region, so we identified a secondary human resources plan that would be able to hire professionals trained at Northern Lights College, which has a campus in one of the communities in the region.
One example of this related to patients needing free physiotherapy to recover from injuries or surgery. There were physiotherapy clinics in the region but we wanted to implement services that could be delivered without patients leaving any of the three communities.
We explored creative solution: tele-physiotherapy. In this model, patients could have their physio at the closest recreation centre with a local fitness instructors, who would receive training in rehabilitation. Then, patients and the fitness instructor would participate in a videoconference with a remote physiotherapist, and the patient could do follow-up visits at their local recreation centre.
Such a solution would solve a few issues including fewer kilometres to drive and less time for patients, making them more likely to complete their prescribed course of treatment. From a human resource perspective it would reduce the need to recruit from outside the region as many rural training institutions provide programs in fitness instruction and local people would be employed in each community.
While this innovation did not make it into the final plan, we felt that the provincial criteria for professionals funded through the PCN may become more flexible as rural areas face inevitable hiring challenges. We also created a backup plan that would see more Licensed Practical Nurses for home visits and interprofessional care, and non-clinicians doing testing for lung function and chronic obstructive pulmonary disorder.
Free, prior and informed consent in healthcare design
In addition to surfacing these creative ideas, the South Peace PCN also co-designed solutions for underserved communities. In the South Peace, Kelly Lake is an Indigenous community on the border with Alberta with a diverse population that includes West Moberly, Saulteau, Cree and Haudenosaunee people. Because Kelly Lake is not a signatory to Treaty 8, it is not served by federal health programs, and the FNHA is unable to provide service due to limited capacity.
We prioritized Kelly Lake early in the process because many participants knew of the community’s isolation and lack of health care options. Members of the community attended one of our committees, and we met with the community to co-design primary care services for Kelly Lake.
Though conversations with elders and an in-person meeting with Kelly Lake community members, we identified unmet needs and designed an outreach strategy to bring the care of physicians and nurses to the community. We listened to their needs and integrated their vision into a larger regional one.
The Primary Care Network used these unique approaches to co-design a set of region-wide primary care improvements that will enable everyone in the South Peace region to get the care they need more conveniently.
In October, the Ministry of Health announced that the plan and funding was approved as it was proposed! Over the next few years, the Network will bring millions of dollars to the region to add more healthcare professionals and network them into a cohesive system.
The City of Dawson Creek also announced that they would purchase a site to house an interprofessional team to serve the community and the region. And now the plan is taking flight to increase available professionals and improve access to the kinds of care that people need and deserve.
For me, one moment summed up the approach we used and the outcome we achieved, when Mayor Courtoreille of Chetwynd BC, a participant in the co-design process described our achievement: “We are all Treaty 8 people. We’re in this together.”
Kudos to the South Peace Primary Care Network leaders and to all of those charting this new, collaborative course to a just, healthy, equitable and prosperous future for us and all our relations.
If you have a challenge and wish to explore how a co-design process can help you, leave a comment!