The Fraser Northwest Division is here to support Family Physicians. We have an array of programs, services, and initiatives available to help support our members. If you don't find what you are looking for on this list, send us an email!
Division programs, initiatives, & supports
Helping you recruit new MOAs more easily
Get a free website created for your clinic
Free MHSU supports for your patients
Receive patient feedback for improvement
Division programs, initiatives, & supports
The relationship between family physicians and specialists is fundamental to the delivery of effective health care. Gaps in communication between health care providers can impede the flow of care, resulting in a fragmented experience for patients, caregivers, and families. The overall goal of Shared Care is to provide a coordinated and seamless health care experience for patients.
Shared Care is one of four Joint Collaborative Committees (JCCs) representing a partnership between the government of BC and Doctors of BC. Funding from Shared Care supports family physician, family physician with a focused practice, and specialist collaboration on quality improvement projects.
Do you have an innovative project idea that could fall within the scope of Shared Care? Are you interested in joining one of our existing projects as a committee member? Please contact Sanjam Jhawar to learn more!
Maternity Care Shared Care
Older Adult/Medically Complex Shared Care - Coordinating Complex Care Initiative
Adult Mental Health and Substance Use Shared Care
Palliative Care Shared Care
Geriatric Psychiatry Shared Care
Chronic Pain Shared Care
Acute Discharge Shared Care
Women's Health Shared Care
Long Term Care
Committee: Long Term Care Initiative Medical Advisory Committee (LTCI MAC)
The purpose of the LTCI MAC is to monitor the improvements and effectiveness of the Fraser Northwest Long Term Care Initiative Program. The committee serves in an advisory capacity, making recommendations on matters that impact the initiative’s ongoing progress, value and sustainability. This committee brings together individuals to:
Provide a network of engaged physicians to increase learning, communication and support on Long Term Care topics
Be a collaborative, positive and rational force for optimizing care for patients in long term care.
Advance physician engagement and increase awareness of our LTCI
Long Term Care Initiative
The Long Term Care Initiative aims to address and support the deficit in the number of FPs interested in caring for an increasing number of frail patients. Physicians want to provide good quality of care and that it is increasingly challenging to do so with the demands on their time. FPs who are interested in becoming a part of our Division’s LTCI program understand that the culture of care is moving forward to a palliative care approach and that FPs play an important role in developing relationships with families, promoting information and having those conversations about prognosis and future decision making. The LTCI program focuses on improved patient health outcomes, improved patient family and provider experiences and optimized cost per patient.
The FNW Long Term Care community has coordinated efforts to support FPs in optimizing care for their patients in residential care through implementing these five best practices:
FP participation in care conferences
Proactive FP visits
Meaningful medication reviews
Oncall support network
First of all, annual care conferences are imperative for allowing an open flow of communication between residents, their families, facility staff and physicians. Physicians are the central figure in authoritative decisions and without their participation, key care decisions are delayed or do not occur.
Secondly, proactive FP visits can ensure medical concerns can be identified before they become urgent, reducing emergency room visits by residents. The new standard of care recommends visits to be done at least every three months, and scheduled facility visits every 14 weeks depending on patient roster size.
Meaningful medication reviews are most successful when they are completed with nurses, pharmacists and FPs. When the whole team discusses polypharmacy interventions, there are increased benefits such as decreased mortality and transfers to hospital.
Additionally, there is great importance in completed documentation as it allows facilities to maintain accurate records, which minimizes delays for resident care, supports oncall FPs when caring for your patients and ensures that patients have up to date advanced care planning. The expectation is for every resident to have a chart note for each FP visit, and to have the admission history forms, the MOST and the advance care planning forms completed shortly after admission.
Lastly, the most important component of the initiative is the oncall after hours program. This program will provide reliable, timely after hours care for residents, with the goal of reducing unnecessary and inappropriate hospital transfers. This oncall network provides after hours care for every resident in our community.
For more information on the Long-Term Care Initiative in Fraser Northwest, please email Michiko: firstname.lastname@example.org
Committee: Recruitment, Retention, & Retirement Advisory Committee
The Recruitment, Retention, and Retirement Advisory Committee (RRRC) is a standing committee established to advise FNW on recruitment, retention, and retirement activities. The goals of the committee are:
To increase the number of primary care providers practicing in Fraser Northwest;
To create opportunities to improve retention by identifying and providing recommendations on the challenges and barriers of primary care;
To increase the early identification of FPs retiring in the community and easing the transition into retirement as well as engaging and finding a way to retain the knowledge of these retiring physicians;
To create a unified and consistent collective voice in the form of quarterly communication to the Provincial GPSC Physician Recruitment & Retention Committee of our needs.
This committee is intended to meet at a frequency of once per quarter for 3 hours. The RRRC is looking for members to join and participate.
HR Program Supports:
FP & NP PCN Contracts
There are FP and NP PCN contracts (salaried) available in the FNW region that offer new providers an alternative to the standard fee-for-service. The Division HR team will facilitate and act as a liaison between the provider, practice, and Fraser Health Authority during each step of the contract process.
To aid in recruiting providers, the HR team is available to create a customized recruitment brochure highlighting the practice, the team, and the space. This visually appealing and informative brochure can then be provided to candidates and referrals interested in the practice and/or region to highlight available opportunities.
The Division HR program can assist physicians and practices recruiting locums or permanent positions (FP/NP) by posting vacancies on Health Match BC, SGP, and the FNW Division website. Upon receiving applications/referrals the HR team will connect the candidate and practice/physician to see if there is a match.
To assist with business and practice management the HR program offers HR consulting to members. Topics may include but are not limited to employment legislation/standards, contract drafting, employee performance, team engagement, etc. This can be offered via email, call, or in-person.
If members are interested in joining the RRRC or are interested in any of the HR Program Supports, please contact Richelle Hughes at email@example.com.
Committee: Practice Improvement Committee
This committee has been formed to provide direction for the Practice Improvement work that the division is embarking on. We always wish to ensure we are meeting the needs of the members. The committee is currently looking for more physician members, contact Patti if you are interested.
IT, Privacy, & Security
Our IT Coordinator collaborates with the board of physicians and various committees to implement a plan to start on the path of creating a security culture within family practice, and increase awareness of common safeguards to protect patient’s information. IT, also helps with supporting technical troubleshooting and assessments of all our members clinics.
MOA & Practice Manager Network
The Division MOA Network offers a variety of resources for both the MOAs and the practices. There is a Facebook page that lists events, resources, and allows for any discussion related to their roles. There are also monthly MOA events that allow for continuous learning. The topics for these events have included Pathways, medical billing, clinical skills, and PCN. In addition, there are Practice Manager meetings every two months where there is learning and collaboration on a variety of topics such as workflow.
This database contains MOAs that have been screened, interviewed, and reference-checked by Division staff. The MOAs in this database, which can be accessed through the Division Portal, are listed with their education, experience, resume, EMRs, wage, and availability. This saves the practices' valuable time.
Website Development & Online Booking
The division Website Development & Online Booking initiative offers members a free* website for their clinic, fully built and maintained by division staff. This in-house web development allows members to customize their website to meet the needs of the clinic. Additionally, should the clinic wish to implement online booking, we provide assistance with sourcing an online booking vendor, setting up demo calls of the various online booking platforms, and initiating the implementation process, along with adding online booking to your clinic website. Online booking is also funded* by the division, so the clinic would simply forward us the invoice for reimbursement.
* For physician-owned practices
Patients needing a family physician register on the FNW Division Patient Attachment Waitlist Registry via phone, email, or a link on the Division website. The Division continuously reaches out to providers in the FNW Region to inquire about their patient capacity. In addition, providers reach out informing the Division that they have the capacity. When there are providers accepting patients, patients on the waitlist are then attached to the providers in their specific community. Click here for the waitlist.
Primary Care Network
Overseen by: Primary Care Network is a partnership and agreement between Fraser Health Authority (FHA), Kwikwetlem First Nations and Fraser Northwest Division of Family Practice to increase patient attachment, access to primary care and overall population health for the community.
The reporting and funding is through the Primary Care Division of the Ministry of Health. The Division has a few committees that report up through this work:
Primary Care Network Steering Committee reports to Collaborative Services Committee
Primary Care Network and Patient Medical Home Physician Advisory Committee reports to the Primary Care Network Steering Committee
FNW Virtual Care Hub Committee reports to Primary Care Network Steering Committee
RN in practice Leadership Committee reports to the Primary Care Network and Patient Medical Home Physician Advisory Committee
If any of these topics are of interest, please contact Kristan Ash to attend a meeting and see if it is a committee you might be interested in participating in. All meeting time is compensated at a sessional rate.
Registered Nurse in Practice
As part of the PCN work occurring in Fraser Northwest, family practices in New Westminster and the Tri-Cities are being offered funding and overhead to work with registered nurses in practice.
What’s in it for your practice?
This RN role is meant to support practice staff in providing the best possible care for patients. Examples of tasks the RN can do which may help elevate the care your practice provides are:
Review panel and ensure all preventative cancer screens are completed
Review lab work
Complete complex care plans
Independent visits for direct patient care (i.e. chronic disease management, screening and health promotion)
Complex appointments such as new intakes, post-discharge and planning visits
Education and self-management support of patients
To be eligible, the clinic must meet the criteria below:
All clinic Physicians must be members of Fraser Northwest Division of Family Practice and practicing in New Westminster, Coquitlam, Port Coquitlam or Port Moody.
Clinic must have a minimum patient panel size of 2500
Agree to participate in practice-level evaluation and reporting
Nominate a Physician Champion. Physician Champion is paid by sessional. The time commitment is approximately 2 hours per week (maximum) in the initial implementation and 2 hours per month once full implementation is completed.
If interested, please contact Richelle Hughes at or Patti Scott at firstname.lastname@example.org.
SHARE Society PCN Counselling
The Primary Care Network (PCN) Counselling Support Services program is a rapid access program meant to assess, stabilize, support and refer on family doctor patients with mild to moderate Mental Health or Substance Use concerns. Clients of this program will receive short term counselling from skilled counsellors to help address their needs. If it is determined that other services are required for further support then the PCN Counselling Support Services program will facilitate access to the most appropriate services in the community with a warm transfer from the program to the new service.
The PCN Counselling Support Services program is designed to respond to Doctor referrals within the same day and set an appointment with the patient within 48 hours of this initial contact. Short term counselling and needs assessment help to determine what other community services may be needed for the client. Once this is determined then the counsellor will work with the new community service and the client to provide a warm transfer from the PCN Counselling Support Services program to the appropriate community service(s).
Counsellors can meet clients at their Doctor’s office, at home, in the community or at our main location.
Find the referral form on Pathways: https://pathwaysbc.ca/clinics/1467
FHA PCN MHSU Clinicians
Available directly with and without a physician referral.
Mental Health and Substance Use Triage: Brief case review to determine what Mental Health and Substance use services are needed for the client and to ensure a warm transfer to said services (including to psychiatry/Mental Health and Substance Use teams if needed).
Case Review/Liaison to Mental Health and Substance Use Services: FP will have direct access to the MHSU PCN clinician for quick review of cases or follow up regarding the status of a referral, including clients seen at the Mental Health centre. This service is also available for SHARE clients who are connected to the Mental Health centre for services.
Reside within geographical boundaries of FNW Division (New West/Tri-Cities)
19 years of age +
Patient has a Mental Health and/or Substance Use condition
Patient has a designated community FP who is willing to work with a Mental Health Clinician
PCN Referral form found on Pathways here
Contracts - for both Family Physicians and Nurse Practitioners
There are salaried contracts available for new to practice FPs and NPs as an alternative to fee-for-service. The contracts are for the family practice setting and salary is based on patient panel size expectations. If you are interested or would like to learn more, please contact Richelle Hughes at email@example.com.
Overseen by: Communications Committee
Through our Monthly Update newsletter and bi-weekly Fast Facts emails to members, we aim to help family physicians stay informed on what’s happening in our community. These emails update members on GPSC changes and fee payments, webinars, MainPro+ credit events, Division events, healthcare delivery surveys, and new community programs that physicians can refer their patients to. We also ask a quick survey question in each of our Fast Fact emails to help direct our work at the division, and ensure we are aligning our work with our members’ needs.
In addition to our regular educational events, we have various 'social' events in the year for our primary members to recognize their commitment to the community and meet and socialize with local colleagues and their families. These events include:
Annual General Meeting - All members, elect Board members, recognize commitments in the community and network with colleagues (September)
Holiday Dinner & Dance - All primary members and their significant other, live band, dinner, dancing, games and lots of socializing
Santa Family Brunch - All primary members and their families, brunch, crafts, cookie decorating, photos with Santa
Playland Family Day - All primary members and their families, BBQ, rides, socializing with colleagues and family
Overseen by: Each division has a Pathways Physician Lead. Physician Leads are asked to attend User Group meetings every two months.
Pathways is the place to connect with community resources and medical specialties. Physicians and medical staff can use Pathways to find out referral wait times for specialists and clinics in our communities, along with patient and physician resources, forms, requisitions, as well as community service and allied health information that is categorized and searchable. For more information about Medical Pathways please email Erin.
Pathways Community Services
The Pathways Community Services website is new as of 2019, and we were the second division to launch the website for our community. This website is fully accessible by the public, and it holds much of the same information that the physician-private side of Pathways offers, including resources in our communities such as mental health, addictions, end of life care, seniors services, pregnancy care, and much more. Additionally, the site has a calendar which is updated with community health events and other local events for the public to attend. The website is maintained by the division in conjunction with the provincial Pathways team.
If you know of a service or useful patient information that is not listed on Pathways, please contact Emily to have it added.
Overseen by: Evaluation Committee (currently looking for more members - 2 open positions)
The Evaluation Committee is responsible for vetting any program or project evaluation reports for internal or external dissemination. The committee ensures that there is physician leadership providing guidance and direction to evaluation in the FNW. Minimum commitment includes attending quarterly meetings and vetting program evaluation reports throughout the year. Sessional payment is available for attending meetings. For more information, see the Evaluation Terms of Reference.
The evaluation program works alongside the program and project teams and stakeholders to support collaboratively building and integrating evaluation mechanisms throughout the duration of any project. These mechanisms are built to link directly back to the overall program/project objectives and are used as key indicators to support program implementation and movement towards overall objectives. The evaluation program supports the ongoing collection, analysis and reporting out of these measures to project teams, project partners, stakeholders and funders. The evaluation program is always looking for new and adaptive ways to collect and share information that informs ongoing program development.
If you are interested in joining the Evaluation Committee or have any questions about evaluation please email Jessie.