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Medical student Ashna Asim with Dr. James MacKillop after a busy day at the collaborative family practice in Sydney.

Meeting the needs of patients with complex needs: A medical student’s reflections on collaborative care in Cape Breton

By Ashna Asim


When I first came across the term “patients with complex needs” as a medical student, I didn’t fully understand what this meant. I wondered, doesn’t every patient have “complexities” in their life experiences, resources and needs?

On a philosophical level, perhaps the answer is “yes.” However, the Agency for Healthcare and Quality defines patients with complex needs as “persons with two or more chronic conditions where each condition may influence the care of the other condition.” One could also add that socio-economic status is also a major factor in complexity. This summer, to better understand complex patient needs in primary care, I had the privilege of job-shadowing Dr. James MacKillop and his team in Sydney. Being a part of a research study on collaborative care has allowed me to better understand the Cape Breton community and gaps in community resources. 

The Sydney practice is one of many collaborative family practice teams across the province. The Sydney collaborative practice includes physicians, a nurse practitioner, a family practice nurse, a social worker, a dietician, and the administrative team. There is also a licensed practical nurse on site. The collaborative care model is a movement to enhance patient-centered care by optimizing the use of health care workers to ensure patients have access to the right providers at the right time.

Common barriers for complex needs of patients include lack of time and fragmented care. The collaborative care model can address, and ideally overcome, these barriers. Health care providers in the Sydney practice mentioned the lack of hierarchy, a collegial environment, and the ability to work together as highlights of the collaborative care model.

When patients ask what collaborative care is, the social worker in the practice explains that because the need for family doctors is so high in our community, in combination with challenges in recruiting physicians, other health care professionals are being included to create a team approach so more patients can be seen and complex needs can be met in a comprehensive approach. Furthermore, access to a social worker as part of a family practice team is seen as an advantage and is well-received by patients.

Another advantage to the collaborative care model is having an interprofessional team that includes nurse practitioners. The nurse practitioner’s role is to assess, diagnose and manage common acute or chronic conditions. While some patients are familiar with the role of a nurse practitioner, for others, being seen by a nurse practitioner was a new experience. One patient noted that he was very pleased to see a move to include more nurse practitioners in primary care as it is filling a large gap for Cape Bretoners.

Nurse practitioners and family practice nurses can devote more time, up to an hour, for their appointments. As a result, appointment types such as well-woman and well-baby visits are often managed by the nurse practitioner and family practice nurse. Furthermore, the nurse practitioner and family practice nurse are also able to dedicate time to chronic disease management and education. A good example of this is diabetes education and a comprehensive diabetes exam.

For me, this was best demonstrated by my encounter with a patient with complex needs, whose story moved me. What struck me about the patient was how, during the appointment, her chief complaint was unraveled to reveal a myriad of factors, including: socio-economic status, old age, lack of access to transportation, and a lack of family and community supports. Patients like her may have many co-morbidities which are entrenched in the social determinants of health.

In Cape Breton, poverty plays a major role. As emphasized by the social worker, generational poverty can instill a “learned helplessness” and apathy in many patients who feel stuck and unable to escape. Having access to an inter-professional team, including a social worker who is able to do home visits for some patients, is an asset for patient care. My encounter with this patient has stayed with me and is a reminder of the importance of striving for effective and collaborative care.

As part of the research study, a question I asked the team was, “what is something that keeps you up at night?”

One physician replied that there are a lot of individuals in our community who are experiencing caregiver burden. It can be very difficult for caregivers if they are unable to manage their loved ones’ health condition. Caregivers need resources to help manage and cope, but often there are not enough community supports available. Caregiver burden and chronic disease management are key issues for the Cape Breton community, which is largely an ageing population. Some patient encounters I saw included discussion on long-term plans, including looking into long-term facilities. Furthermore, as highlighted by the social worker, Nova Scotia is behind in ensuring that all patients have personal directives and a living will in place and on file in their medical records.

Other barriers highlighted by the team included lack of access to transportation, in large part due to limited public transportation available in Cape Breton. This prevents many patients from being able to attend appointments. Another major barrier is the gap in mental health services, with waitlists up to a year. In light of this, many members of the collaborative practice, such as the nurse practitioner and social worker, will follow up and manage patients while they wait for mental health services. Limited resources in Cape Breton was a major theme in the discussion of challenges faced by patients.

The Sydney practice is a new collaborative practice and is continuing to work on refining its collaborative care framework. As pointed out by a physician, the goal is to have “effective collaboration, not just co-location.”

I am grateful to the health care team, research team, and especially the patients I had the privilege of meeting for what has been a valuable and enriching experience. For medical students such as myself, it is hopeful to see so many incredible health care professionals and researchers working together to provide better care for our community. 


About the author

Ashna Asim is a third-year medical student from Sydney, studying at Queen’s University in Kingston, Ont. Her passion for stories and community service drew her to medicine.

Throughout her studies, Asim has worked in the community with women’s shelters, youth shelters, and has mentored newcomer youth and girls of colour. She is passionate about social justice, humanities in medicine, health promotion, and striving to improve health care quality and access.


About the opportunity

During the summer of 2018, Asim participated in a research study funded by the Nova Scotia Health Research Foundation, led by Dr. Ruth Martin-Misener, Dr. Tara Sampalli and a large research team which included patients. The study looked at, “what does patient-centred, team-based care mean for Nova Scotians specifically for those with complex conditions and needs such as having multiple chronic conditions.”

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