The HealthConnection Clinic: Providing Primary Care for Vulnerable Members of Society

This award was formally named “Living with Illness”. Our Excellence in Quality category names changed in 2020 to reflect the updates to our BC Health Quality Matrix. Visit our Categories and Criteria page to find out more.

The HealthConnection Clinic is located across the street from Lion’s Gate Hospital in North Vancouver and features an interdisciplinary professional team that provides low barrier access to primary care for those who have complex medical and social needs and who cannot attach to a traditional family practice. The clinic’s focus is on addressing both health challenges and the social determinants of health. Team members include family physicians, nurse practitioners, social work students, outreach workers, a chronic disease nurse and medical office assistants.

The clinic is a partnership between the North Shore Division of Family Practice and Vancouver Coastal Health. The Physician Information Technology Office and the Practice Support Program have been working together to ensure the clinic works efficiently and with the necessary technology.

Clients who visit the clinic are among the most vulnerable members of our society, experiencing addictions, mental health challenges, and a myriad of chronic diseases that require the active involvement of a health care team in order to prevent long-term, serious complications.

When the clinic was established, its team developed a screening process to ensure that those who access the clinic are truly high-needs clients who are unattached to a GP. The clinic adapted the Minnesota Complexity Assessment Method, which screens clients on a number of criteria – both medical and social – and has revealed that 65% of clients have no GP/NP or have not seen one in the last 12 months due to access/other barriers; 23% of clients use the emergency department as a primary source for health care or visited an emergency department 4 or more times in the last 12 months for episodic concerns; and 71% of clients have difficulty making ends meet all or most of the time.

Numerous community agencies place staff within the clinic on specific days in order to provide service to clients. For example, outreach workers from the Lookout Shelter or social workers from Hollyburn Family Services assist clients with their housing situations or other social needs. These partnerships have also resulted in a high number of referrals from the partner agencies. For example, 38% of referrals to the clinic come directly from the Lookout Shelter.

A developmental evaluator works closely with the clinic’s team to rigorously track data; as a result, the clinic has solid evaluation results that demonstrate a measurable impact on the health care system and the lives of its clients. Since opening in July 2013, 307 clients have made over 1,645 visits. Clients who have attended the clinic more than twice have seen a reductions in hospital admissions (-22%), , hospital admissions from the emergency department (-42%), and alternative level of care days (from 11.0% to 0.0%).

Every 2-3 months, clients are selected at random to participate in feedback interviews that are usually conducted while they wait for their appointment or after they have seen the practitioner. There is also a suggestion box in the clinic waiting room for clients to offer their improvement ideas. As a result, the clinic now offers small snacks as well as hats and mittens in the winter. Clients are also now offered a separate waiting room if they are having an acute episode or have strong scent allergies and cannot wait in the regular waiting room. The clinic is actively seeking more mental health support as clients identified a lack of dedicated mental health clinicians available in the clinic. The clinic is also working to expand its hours (currently it is only open from 0900 – 1200, Monday to Friday), since 84% of its clients’ emergency department visits occur outside of operating hours.

Team members that work in the clinic are extremely positive about their experiences providing whole care to clients in need. Health care practitioners, particularly those referring to the clinic and emergency department staff, are very pleased that primary care is now an option for clients who otherwise have no ongoing care.

The clinic continues to operate within the framework of the Institute for Health Improvement’s Triple Aim and continuous quality improvement. Clients who frequent the HealthConnection Clinic have often had previous negative experiences with the health care system. The clinic’s environment is a welcoming space, and clients have recounted how they now have a better experience in the emergency department when they are sent directly from the HealthConnection clinic. A cost analysis completed with the first 9 months of clinic data demonstrated $183,000 in total cost avoidance for the acute system. As a result of this success, the clinic is helping to shift care from acute to more appropriate community-based primary care services.

The clinic was opened on a shoestring budget to meet local community needs. Space already funded and, at the time, under-utilized by Vancouver Coastal Health was obtained. Nurse Practitioners who work with vulnerable populations and a chronic disease nurse coordinator were redeployed to the clinic. One-time funding was also obtained to fund GP sessions, a part-time medical office assistant and basic supplies. The clinic is currently trying to secure additional funding to expand its current level of operation.

Next steps being explored for the clinic include expanding operational hours to full days (five days a week) and implementing an outreach/home visiting component for home-bound clients, including frail, socially-isolated seniors. Many innovative practices are being developed, including a collaborative care plan. Opportunities to expand knowledge and treatment options for clients suffering chronic pain and addictions are also being explored. Similar to when the original proposal for the clinic was first developed, the clinic team is working on a comprehensive expansion plan and will be reviewing various outreach models and resources already available on the North Shore to determine the best approach moving forward.