Pass it on! Innovative approaches to making a difference in healthcare 

Nurse practitioners and physicians collaborate for improved patient care at B.C.’s Interior Health Authority

by admin admin | Feb 01, 2009
Is it possible for nurse practitioners and physicians to work side-by-side in a traditional fee-for-service setting? Most definitely, say the staff at British Columbia’s Interior Health Authority, which is successfully pilot-testing a model of care that has health authority-funded, salaried nurse practitioners working collaboratively with physicians in a group practice environment.

Key Messages

British Columbia’s Interior Health Authority is pilot testing its Nurse Practitioner /Family Physician Primary Health Care Model, which has health authority-funded, salaried nurse practitioners working collaboratively with physicians in a fee-for-service group practice environment.

Key to the successful implementation of this model is clarifying roles, addressing funding issues with the physicians, and managing change effectively.

This collaborative model has had a significant positive impact on the delivery of patient-centred primary health care in the region, as well as on patient, physician, and nurse practitioner satisfaction. There has been a 100% retention rate among nurse practitioners after four years.

When the opportunity arose to integrate nurse practitioners into British Columbia’s healthcare system, Linda Sawchenko immediately saw even greater potential: a way to drastically improve primary healthcare across the province, while still acknowledging long-standing concerns from physicians about potential loss of income.

In 2005, the B.C. government introduced regulations, along with dedicated funding, to allow for the introduction of nurse practitioners into the province’s healthcare system. Communities were experiencing primary care shortages – there was an urgent need for improvement and change. Both Sawchenko, regional practice leader with B.C.’s Interior Health Authority, and Tom Fulton, Chief Professional Practice, Nursing and Quality Improvement, recognized that the timing was perfect to bring nurse practitioners into the picture.

The first order of business was to decide where nurse practitioners could be used to best meet the primary care needs of the population, which turned out to be in primary care physician practices. However, hiring nurse practitioners into this setting presented formidable challenges. “We recognized that most of our primary care was being provided by physicians on a fee-for-service basis,” Sawchenko explains, “but the nurse practitioners were salaried workers. We had two systems that were not well aligned.”

Sawchenko realized that the first step forward would be a giant one: closing the gap between the fee-for-service physicians and the health authority-employed, salaried nurse practitioners. She began by reviewing the research literature, particularly that related to barriers and facilitators to the integration of nurse practitioners. Based on the evidence, and using best practice frameworks as a foundation, Sawchenko designed a collaborative model of primary care for Interior Health – one that has salaried nurse practitioners working collaboratively with physicians in a fee-for-service group practice environment. The model is currently being pilot-tested in three rural clinics: two in the community of Trail and a third in Castlegar, and has recently expanded to include a large urban site in Kelowna.

Alleviating concerns

A major barrier to integrating nurse practitioners into a fee-for-service model is physicians’ concern about loss of income. Sawchenko and her colleagues addressed the funding issues with the physicians right up front and made it clear that the project was not intended to cost them anything. In fact, to help ensure success, the Health Authority decided to provide physicians with an overhead budget to offset the real costs of having a nurse practitioner in their practices, an initiative “that worked really well,” according to Sawchenko.

They just made me happy in my nursing career, to be able to collaborate with people on a daily basis to provide care.

Something else that worked well was the creation of a professional community of practice for the nurse practitioners. Sawchenko recognized the need for the nurse practitioners to feel connected and supported, since many of them are novices, working in new roles, spread across a large geographic area, and often lacking mentorship in their own settings. This community of practice, now well established, gets together several times a year, in person and through electronic media.

Creating a three-way win

So how are things working? According to feedback gathered from patients and providers, the response has been overwhelmingly positive. One year into the pilot project, having salaried nurse practitioners working alongside fee-for-service physicians has generated rave reviews from patients, nurse practitioners, and physicians alike. Everyone involved appreciates the teamwork and how the nurse practitioner’s scope of practice complements that of the physician. This model of care also improves job satisfaction through shared decision-making, responsibility and workload.

The nurse practitioners themselves express high levels of satisfaction; many say that the collaborative model of primary care delivery is exactly what they had hoped for. Nurse practitioner Barbara Nielsen, from the Selkirk Family Medicine clinic says, “This just made me happy in my nursing career, to be able to collaborate with people on a daily basis to provide care.” And the proof is in the numbers: there has been a 100% nurse practitioner retention rate after four years, which Sawchenko firmly believes has been largely due to the collaborative model of practice.

As for the physicians, their work life has improved significantly. As one physician noted, “This model makes primary healthcare easier and more sustainable.” Dr. Marnie Jacobsen from Selkirk Family Medicine clinic elaborates: “The provision of care is quite complex considering the aging population, the complexity of patient care, and the increase of medications and treatments. It is hard, as a single physician, to cope with this complexity. A significant, sustainable solution for primary healthcare is using the nurse practitioner in a team approach, with the option of adding other healthcare professionals as well.”

For patients, having a physician and a nurse practitioner is the best of both worlds. Patients say they have better access to healthcare services, receive more collaborative care, and feel like active participants in the healthcare team. They report feeling empowered and part of the decision-making process.

At the Selkirk Family Medicine clinic, Nielsen says the patients are receiving the best comprehensive care she has seen in her 30 years of nursing. “It is a true partnership between the patient, me, and the physician,” she says. Part of her role is responding to physician requests to conduct urgent home visits for seniors at risk. By supporting these frail elderly clients in the community, she is providing client-centred care and preventing emergency room visits. Dr. Blair Stanley from the Waneta Primary Care Clinic says that since the arrival of the nurse practitioner, his clinic’s patients are experiencing fewer emergency room visits, fewer hospital admissions, and improved access to care– often same-day or next-day access. The clinic has also increased its patient volume by 600 people.

Despite formidable barriers, Interior Health is demonstrating how it is possible to successfully bring nurse practitioners and family physicians together to improve primary healthcare delivery and keep people healthy. Based on results to date, Interior Health plans to expand the project and conduct a more formal, quantitative evaluation.

Sawchenko believes that an important element of ongoing success is a focus on change management: not change for change’s sake, she says, but really thinking about how to introduce the change and sustain it. “If we don’t continue to nurture the change,” she explains, “we could see the successes we’ve achieved lost.”


Pass it on! is a publication of the Canadian Health Services Research Foundation (CHSRF). Funded through an agreement with the Government of Canada, CHSRF is an independent, not-for-profit corporation with a mandate to promote the use of evidence to strengthen the delivery of services that improve the health of Canadians. The views expressed herein do not necessarily represent the views of the Government of Canada. © CHSRF 2010