Contents:

Primary Health Care Planning Meeting, June 20, 2008

Appendix B: The Morning Sessions

The June 20, 2008, meeting regarding Primary Health Care on Gabriola was hosted by the BC Ministry of Health, The Vancouver Island Health Authority, and the Gabriola Health Care Society. In the morning the participants were asked to list the topics that they wished to have discussed and then attend a discussion of three of the topics listed by the whole group. The following are the unedited participant comments in these sessions as recorded by one member of the discussion groups. While the comments will all be taken into account by the Gabriola Heath Care Society in formulating its goals and plans for the future, the views expressed are those of the participants and not necessarily those of any of the hosts. The inclusion of the comments here does not suggest that any of the hosts either endorses or supports them.
Topic: Why can’t government provide money for on-call?

1. Describe the topic:

  • With stats showing that this year Gabriola has saved the Nanaimo Hospital $400,000

2. What is going well?

  • VIHA agreed to supply all emergency supplies. It is accepted that this is good savings on the global community

3. What is not going well?

  • Not enough stat’s, actual savings to show in efficient ER
  • VHA not funding ongoing equipment
  • Changes to MOCAP, confusion have lead to a stalemate  
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Topic: What incentives does the provincial government provide to encourage another doctor to come to the Island? What incentives can the Island provide?

1. Describe the topic:

2. What is going well?

  • Patients find that the emergency room here works better than in Nanaimo

3. What is not going well?

  • There is a “shortage” of housing for doctors arriving
  • Doctors need a manageable call schedule (also need to attract a Locum)
  • Clear articulation of incentives needed to attract doctors
  • Pilot programs come and go
  • Need to recruit according to a welcoming philosophy, doctors should be able to arrive and just unpack their suitcases
  • Lion’s Club?

  • How can we support in terms of helping with administration
  • Provide housing, child care, time off and encourage a good balance of life versus work
  • How do we get the people on the island on-side – stop the Undermining!
  • Create a stable, functional environment
  • Provide stability, promote the ‘lifestyle’ – housing, memberships, social
  • What about the concept of doctors being paid per patient for managing their entire health (rather than ‘piecemeal – by the visit)  
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Topic: What are the basic requirements to maintain our present care re: doctors?

1. Describe the topic:

2. What is going well?

3. What is not going well?

  • Not enough doctors to share on-call burden
  • Dr’s not being paid to be on-call (i.e., available to be called out)
  • Paramedics are
  • Other similar communities do get paid this!
  • History of doctors NOT providing on-call on Gabriola due to burden on lifestyle/stress
  • If doctors called out lose $ by not being able to see own patient due to fatigue or being away when supposed to be seeing regular patients
  • Misconception that Dr’s earn a lot of money – but what doesn’t get considered is they have overhead – pay their staff, rent, etc.
  • On-call issue is big because it not only provides compensation but helps to attract new physicians
  • Stability is an issue too – knowing that we have physicians available here allows us to choose to move our healthcare here – thus doctors more willing to locate here because of stable patient base
  • Issues around ‘splitting’ patients – seeing more than one physician – one on Gabriola and one in Nanaimo
  • We need to know what the government is actually planning for health care
  • New Zealand model?

    What can be implemented here?

  • Improving integration/communication between different health agencies on the Island
  • Maybe healthcare funding on the island can be redistributed to meet our needs and priorities
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Topic: How can GHCS the Community insure adequate on-call coverage for the trauma room for the doctors on the Island?

1. Describe the topic:

  • Adequate on-call coverage

2. What is going well?

  • There is coverage

3. What is not going well?

  • Only one doctor covering 24hr call
  • On call funding
  • Recruit physicians to cover
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Topic: How can emergency funding be organized?

1. Describe the topic:

  • Organization of emergency funding

2. What is going well?

  • None
  • We don’t know
  • VIHA has responded somewhat and supported meetings...
  • GHCS has raised funds to establish an emergency facility and provide some equipment...

3. What is not going well?

  • Streamlining of funding pathways
  • A lot of ass-covering, a lot of talk, nothing gets done
  • Recycled emergency equipment?

    Substandard equipment
  • Pathways which can lead to adequate funding – which VIHA subgroup?

  • Physic ian recruitment
  • Quality of equipment
  • Adequate compensation for physicians
  • Implementation of existing funds are being hampered by inter-government dysfunction
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Topic: Why don’t we use more Nurse Practitioners to aid doctors?

1. Describe the topic:

  • How are nurse practitioners funded?

    Salary
  • Parameters – full scope of practice, have a roster of own patients
  • Need physician to support nurse practitioner

2. What is going well?

  • Opportunity for community to define what Nurse Practitioner can do and what ‘we’ need
  • Opportunity for educational awareness of NP roles from VIHA so community could decide roles
  • Opportunity to free up doctor
  • Opportunity to reduce workload re: complex patients
  • No resistance from MD”s – just needs to be planned through challenges for ‘win-win’

3. What is not going well?

  • May not work as well in small practice setting
  • NP’s are novice in practice
  • Application for NP is required – physician endorsement
  • NP can’t fully replace MD re: on call
  • Team approach required to ensure MD’s don’t lose$
  • MD’s on call situation means “no life” at home
  • NP won’t remove on-call issue 24/7
  • Nurses vs doctors
  • NEXT STEP: GHCS needs to look into this Issue and Plan
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Topic: How can we develop nursing and family practice training into the local system?

1. Describe the topic:

  • As I am the only person interested in this question, I will contribute what I know (others joined)
  • There are ++ nursing students who need experience in areas of the community. A Health Centre can easily become a placement centre -- contact Vancouver Island University School of Nursing to negotiate this
  • UBC has a family practitioner residency in Nanaimo Dr. Beerman is the contact
  • Nurse Practitioners have traditionally been hosted by family doctors and this will continue – could use More of them
  • Nurse Practitioners – has a pay scale been established?

    Yes. Nurse Practitioner is practicing, paid by VIHA, at the Medical Arts Centre
  • Can Nurse Practitioner be on-call for the emergency room on Gabriola?

  • Feel we need pain management services on the Island – either by nurses or whoever provides pain management. Often these problems can be solved with assistance at home instead of going to the ER in Nanaimo

2. What is going well?

3. What is not going well?

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Topic: How does Home Care get integrated into Clinic?

1. Describe the topic:

  • Co-location of home-care services at clinic
  • Improved communication between practitioners
  • Broken network when it moved to Nanaimo

2. What is going well?

  • Caseloads are being managed
  • Staff are Island residents

3. What is not going well?

  • No centre for Home Support on island
  • Scheduling should be done from Gabriola
  • Home support hard to get
  • Gaps in service, frequency, access
  • Lack of education of islanders about how to access services, what is available
  • Needs assessment needs to be done
  • Identify # of persons living alone
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Topic: Why isn’t Home Care help organized out of Gabriola?

1. Describe the topic:

  • Need continuity of care and sharing of information between all care providers. Use of volunteers – family support etc. – need to be coordinated by someone
  • Include Hospice in care planning

2. What is going well?

  • First responders
  • Nurses
  • Drop-in clinic (not having to access services in Nanaimo ER)

3. What is not going well?

  • Need for greater collaboration between services
  • Use of volunteers could be better coordinated
  • Not knowing how to access Home care services
  • Suggest articles for local newspaper – Welcome Wagon
  • Lack of nurse practitioners
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Topic: What is the Purpose of the Gabriola Health Care Society?

1. Describe the topic:

  • To provide a center for services that could encourage doctors to stay and incorporating some more government services

2. What is going well?

  • ETR now here
  • The doctors have stayed
  • The community has supported with $
  • The purpose is gradually changing as needs are being identified

3. What is not going well?

  • The ETR seems to be sidetracked
  • Government interference
  • The change in_____? has not been adequately presented
  • Unintended consequences
  • Interactions/relationships
  • Two opinions: questions about what the history is?
  • GHCS: we did what we said we were going to do – brought a whole pile of issues
  • When GHCS achieved the purpose, I don’t understand how it got morphed into that?
  • GHCS: because the society was strongly supported by the community.
  • I was not treated well when I said I didn’t know enough to support it.
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Topic: What kind of primary system to we envision?

1. Describe the topic:

  • Primary healthcare vision – would like to see a central hub

2. What is going well?

  • ETR
  • Community support very strong (not unanimous)

3. What is not going well?

  • Has been loss of community care services because of funding cuts. Could a coordinated facility reverse this trend?

  • Not enough doctors to staff ETR
  • Central – under one roof
  • Multidisciplinary coordinated care
  • Appropriate to local heeds
  • Visiting spec. Care e.g. counselling
  • Chronic are services / home care
  • Acute care (all hours)
  • Training – NP’s, FP’s – University and colleges
  • State of the art technology for telemedicine
  • Evaluation
  • Coordinator to manage
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Topic: What indicates community ownership of a broad definition of health care?

1. Describe the topic:

  • What defines health care system ownership?

2. What is going well?

  • Articles in newspapers
  • Formation of the Society
  • Community funding of clinic
  • Able to attract_____

3. What is not going well?

  • Broader voice in community to expand ownership. How to be done
  • Missionary aspect
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Topic: What exists that will proscribe what we can discuss as to the future?

1. Describe the topic:

  • What’s available, what restricts, and what we want

2. What is going well?

  • The Clinic

3. What is not going well?

  • Back to the broader concept of health care – what can we do to be preventative?

  • Broadening the perspective/meeting needs
  • Model: update NY – health provides outside circle tem approach focussed on patients
  • Accessibility better addressed in one place/under one roof
  • Coordinated team-based approach
  • Home support Must return to Gabriola
  • Lack of coordinated services – everything falls to volunteers and neighbours to help out
  • Mental health issues – no support
  • No drop in or access to counselling
  • No $ for support
  • No crisis response available
  • No public education around services available
  • Integration and access to a team under One Roof clears the way for patients to find the programs and services they need in their own community
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Topic: How did an ETR campaign ‘morph’ into a plan for ‘everything under the Sun?’

1. Describe the topic:

  • The ETR has changed to include all aspects of the Health Care system.
  • Need to focus on what is important

2. What is going well?

  • We are talking!

3. What is not going well?

  • Lost focus of what the original movement was all about. The ETR should be the focus
  • What do we Really Need?

  • Walk in clinics – changes the whole concept of Dr/patient
  • One problem per visit – is this Useful?

  • Need 4 – 5 doctors – full and part time
  • What if MOCAP does not come through?

  • Nurse practitioners for first contact! – somewhat less expensive (NP about $35 per hr)
  • Mental health – don’t have the staff to cover the positions
  • Home care nurses – not enough staff
  • Take a second look at what is Reasonable – not a Wish List
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Topic: Who would you like to see in the Primary Health Care Team?

1. Describe the topic:

  • The range of different health care providers
  • Including parish nurses, navigators – someone who can provide direction to community members - the first point of contact
  • Keep it narrowed down to allopathic – those already covered by the BC Medical system
  • Importance of integrated care – doctors, home care, nurse practitioners, public health nurses
  • Services working and talking together

2. What is going well?

  • there are some services but could they work better together
  • need more services for services

3. What is not going well?

  • The Ideal team would include:
    • Doctors
    • Acupuncture
    • Nursing groups/teams/homecare 24/7/midwifery nurse/public health/mental health and addictions/palliative care/chronic disease/education on a wide range of topics/nutritionists/targeted service for adolescent health issues
    • Social groups
    • Would like a wider range
    • Average age of patients is 60
    • Allied health – physiotherapy, occupational therapist, counsellors, therapists on relationships, school health, family wellness
  • Communication to all Islanders about what is currently available
  • Need more on prevention and education
  • Need a local navigator who knows people
  • Need to work together as a team with review of Membership – including clerical, IT, office manager
  • Services that are available and accessible, consistent and predictable, some permanent and local core members, and others brought in
  • All needs to be supported
  • Team needs good leadership
  • Pay attention to accessibility = friendly, warm, welcoming
  • Need more than a reactionary approach and more of a population health approach, recognition of _____, respecting choice and making informed decisions
  • Need to keep young families here and need to work strategically with community partners and older families – cradle to grave
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Topic: What information/data is required to support planning?

1. Describe the topic:

  • Need for community size
  • Detailed demographic
  • Service utilization
  • Total community profile
  • Comparison to other Islands
  • Should data focus on summer or winter population
  • Health services data demographics
  • Population health data

2. What is going well?

  • Awareness that we need better data
  • MOH & VIHA prepared to work on getting data
  • Rough estimate of winter population, no
  • Supermarket sales – could be looked at
  • Malaspina college working on data
  • Awareness that a community profile is needed

3. What is not going well?

  • Available census data is not pinpointed
  • Ranges of summer and winter population
  • Actual stats are limited
  • No data currently is used for planning, information not being shared
  • Data not well shared with community
  • Dialogue and sharing data for planning with community
  • Data needs to be used to plan a business case for primary health care services
  • Don’t know what to plan for because we don’t have data to trend forward
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Topic: How can we involve patients as partners in Health Care?

1. Describe the topic:

  • Involving patients in taking responsibility for their own care

2. What is going well?

  • People are more educated and have more access to information (computer info, know their bodies, lifestyle information available). We need to make people aware that they are a partner in taking responsibility for their own health. This is starting to happen – more support for active plan health education in elementary school, prevention. Practitioners must take time to explain what self-management is, respect their client, build relationship.

3. What is not going well?

  • If don’t have a personal GP, no relationship.
  • Physicians not looking at whole person – giving annual check up, physicals – assembly line feel. Patients are at the mercy of the doctor – we need them, they don’t have time to listen to what their patient wants to do. We need more doctors. We need to support our doctors more.
  • Depression screening, substance abuse clinics
  • What are the rules in different clinics?

    Only one item can be brought to the doctor for discussion
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Topic: How can we use technology to access services?

1. Describe the topic:

  • Video conferencing – potential use for specialist care, etc.
  • Increased physician efficiency

2. What is going well?

  • Electronic medical records – some physicians on Gabriola already using effectively
  • “Gabriola is electronically progressive”

3. What is not going well?

  • Obstacles – transition to electronic records
  • Consider a media centre for health education
  • Planning the clinic will need to incorporate information technology
  • Could we use technology to increase access during the night?

  • We could utilize the health professional’s ______with technological support and access to hospital services
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Topic: How to measure outcomes without violating privacy?

1. Describe the topic:

  • People with drug addiction/mental illness need information about treatment and which is working. Caregivers need to know what is happening with the person without violating privacy

2. What is going well?

  • (VIHA employee responds - ) Databases where medical information is held is more secure than banking information. Electronic info usually more secure than paper records.
  • First responders are excellent. Have been no ‘leaks’ of patient info. Feel that the professional code of silence is working.

3. What is not going well?

  • If a person goes to NRGH how does the doctor there get info re GP’s records because GP’s here don’t admit to hospital.
  • How do we influence doctors here to be part of an electronic system?

    Some doctors here DO have electronic records. Hopefully, this info can be communicated from doctor to doctor
  • Believe patients should have access to their own records, under FOI
  • Q: does MOH or VIHA look at info from clinics to measure what needs are?

  • A: No. Specific programs will have outcome measures
  • RUMOUR: VIHA rejected #’s which were measured on Gabriola concerning how much was saved by the ambulance taking the patient to the clinic instead of to the ER. (Need more GP coverage for the emergency room here to be more effective.)
  • NEED #’s of how many attend this clinic emergency room to be recognized by VIHA as money/time saved.
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Topic: What population do we need to increase the existing services?

1. Describe the topic:

  • What services are we talking about?

    How much service does an island get – what is it based on?

    Population or politics?

  • How are statistics gathered – if you are a temporary resident your service need starts here – does it get recorded that way?

    That is a problem
  • 50% of residents seek health care off-Island – doctors don’t have privileges at NRGH
  • Lifetime relationship with doctor
  • There are hospitalists in Nanaimo – work only in hospital – take any patient who does not have a physician

2. What is going well?

3. What is not going well?

  • More home support needed
  • Average age 55-60
  • Need more service
  • Care givers need relief need help – burning out. Chronic disease management
  • Gabriola isolation – distance/ferry restrictions/ statistically what is the quota/capacity for service?

  • Consistency of services necessary
  • Need for a 7 day a week support.
  • Need assisted living resource on Island (there are retirement buildings but these are for those who are independent)
  • Main need for increase in existing services is home support for all ages when they need it
  • Emergency Room is Essential to the population of the Island
  • The role of nurse practitioner in support of seniors and physicians
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Topic: Where and how do we locate future clinics (One Health centre)?

Does it include a hospital?

1. Describe the topic:

  • Plan for future in the long term.
  • Is the Fire Hall property feasible?

  • Commons?

  • Central focus is desired

2. What is going well?

  • some emergencies are handled on Island

3. What is not going well?

  • Helicopter not landing due to lack of approved landing zone.
  • Up until now decisions were made independently
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Topic: Why are so few people here today?

1. Describe the topic:

  • People are working, looking after children, etc.
  • There are pros and cons to every and any time that could be picked - accessibility
  • It’s Sunny today

2. What is going well?

  • Website
  • Blog
  • Exchange of ideas, thoughts, concerns

3. What is not going well?

  • Require a variety of ‘points of contact’ e.g., workshops, mail out with postage paid return envelope for people to send questions
  • ‘what do you need to maintain your health’
  • ‘human’ initial point of contact for health care/GHCS who is known and knows how to access help, information, resources
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Topic: What role might the HOPE Centre play in Public Health?

1. Describe the topic:

  • Thinking about the role of prevention in the community and how it can be delivered

2. What is going well?

  • Programs for under 19 yrs. When issues arise referrals can be made to appropriate services re: addictions.
  • 5 staff trained in ‘Triple P’ for parents of children and teens
  • Gathering place is a resource for teens which can support healthy behaviour – drug and alcohol free – well established as the normal culture
  • Full range of prevention based services for children and families
  • Immunization clinics, breast feeding support, day care, teen support, pre-school, after-school program
  • Teens love their programs and do come which keeps them out of trouble and provides an audience for healthy initiatives
  • This becomes an ongoing strategy to support our community

3. What is not going well?

  • Currently, funding comes from a variety of sources, mostly based on fundraising
  • Overall, funding support is poor for prevention
  • For prevention you need a consistent long term service that becomes a part of people’s lives
  • Fundraising itself takes time and energy away from service delivery
  • Hasn’t been much of a connection between Health Care on the Island and Hope Centre up to now – but there is a desire to work together
  • Need an exercise in strategic planning together
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Topic: What kinds of primary health care programs/services would we like to have specific to seniors?

1. Describe the topic:

  • Programs and services for seniors and people with disabilities

2. What is going well?

  • seniors have social/recreational programming through the Rollo Centre
  • great volunteer support

3. What is not going well?

  • No assisted living at all
  • We need to integrate assisted living into any seniors housing with on call assistance
  • Transportation is a barrier – no bus, no handi-dart
  • No health based informational programs for seniors
  • Adult day care?

  • Meals on Wheels?

  • Need to be sure we reach seniors in need (isolated)
  • Need to have a seniors needs assessment
  • Life line program?

  • Food security assessment
  • Confidentiality issues – small community, people fear disclosure
  • Respite beds
  • There is nothing being done on Gabriola for seniors with health issues
  • We need to coordinate “interagency” ongoing monthly meetings to share information and make recommendations
  • No central decision making process
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Topic: Must Primary Health Care include long term care housing for seniors and disabled?

1. Describe the topic:

  • Need for integrated options – ‘the Commons’
  • Office space, community gardens, elders eco-housing, respite care
  • Incorporation of bath program, day programs
  • Want to make Gabriola senior friendly
  • Mobile granny flats

2. What is going well?

  • 2 seniors housing options – apartments/condominiums, small housing units (private rentals)
  • Community gardens, orchards
  • Community planning – interested parties have commenced planning process
  • Neighbourhood watch – looking out for each other
  • Ambulance Society pays for home help for Society members on the Island – care and equipment, cleaning, meal, etc

3. What is not going well?

  • Need to deal with regulatory bodies – Islands Trust, etc., for institutional rezoning (approval for 26 units allowed within zoning) (26 acres)
  • Shortage of appropriate seniors housing
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Topic: How are children and families supported on the island now?

In the future?

1. Describe the topic:

  • What is happening for children/youth/families in terms of prevention and what else is needed or could be provided?

2. What is going well?

  • Hope Centre – peer mentorship
  • Youth involved in services provided on a continuum serving a range of ages
  • Relationships with youth/children
  • 4H Club on Island

3. What is not going well?

  • Future (not happening) providing health services for children youth during times when children/youth gather
  • How to engage introduce families to health services by collaborating with existing services in the community , i.e., the Hope Centre – brings in youth and family addiction services or youth clinic or immunization
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Topic: What kind of mental health/addiction issues would you like to see addressed on the Island?

1. Describe the topic:

  • Need more public awareness of mental health and addictions problems and needs
  • Needs to be raised early in schools
  • Education, intervention

2. What is going well?

3. What is not going well?

  • There is a lot of secrecy
  • Use of peer counselling and support in schools
  • Counselling and support services – availability at emergency clinic
  • Walk-in crisis clinic where anyone can present/access with a crisis, mental health issue, addiction issue
  • Local self-help groups for support – AA, NA
  • Approximately 30 people living homeless on island
  • Need more integration of RCMP in the community
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Topic: How can we improve on our existing transportation system to make sure people get to care on time?

1. Describe the topic:

  • Transportation on the island and to and from the island

2. What is going well?

  • the community is generous with picking up hitchhikers during the day
  • growing awareness for necessity for integrated planning
  • rising cost of gas is making people re-evaluate

3. What is not going well?

  • Bad ferry service
  • No guarantee of schedule and availability
  • No public transportation on island – can we sustain it?

    How about ride share?

  • Lack of community consensus – is a bridge inevitable?

  • If there was a bridge would everything we are discussing now be irrelevant?

    (No.)
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Topic: What other models for health care are there in other isolated communities?

1. Describe the topic:

  • Fee for service and top up if salary does not reach expected level
  • Walk in vs. Family physician
  • Hazelton (50 years ago) some minor surgery, babies, on call, fractures, etc.
  • Public health nurse, mental health
  • Church involvement in health care
  • Galiano full time doctor $250,000 per year salary sets a precedent
  • Need to get an exact job description and honour it
  • Doctors in clinic – salaried positions – duties divided up internally
  • Use medical student practicums for training, recruiting, 1-2 months
  • Year round students?
  • Students initiate treatment under supervision?

2. What is going well?

  • .

3. What is not going well?

  • .
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The following topics were raised at the workshop, but no discussion was recorded:
  • How does the ambulance service integrate with an emergency treatment room?

  • How can the naturopathic practices be integrated into Gabriola care?

  • How about hospital privileges in Nanaimo?

  • How can government assist and support integration of services?

  • How do we address the unique situation of rural plus Island health care delivery?

  • Do we provide assisted living (with health care) on the Island?

  • Extending home care to people who have procedures in locations other than Nanaimo. How can “Gabriola” help to provide this?

  • Stuck in Nanaimo after visiting the emergency room?

    What can we do to change that?

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