Primary Care Innovation: Anji’s Story
Anji is a 50-year old single mother of three who recently immigrated from Pakistan. She was having difficulty finding the right family doctor to help her manage her diabetes, anxiety and depression. Her anxiety and panic attacks became so debilitating she frequented the emergency department of a local hospital. As a new immigrant to Canada, language barriers increased her anxiety and depression.
She came to the Waterloo Region Nurse Practitioner -Led Clinic (WRNPLC) anxious and frustrated. With help from an interpreter, the clinic learned of Anji’s chronic history of diabetes, anxiety and depression. She confided that she had not been taking her medication or having lab work done on a regular basis. A complete assessment was done by the nurse practitioner (NP) who then involved a registered practical nurse (RPN), pharmacist, social worker and dietician in Anji’s care. The team created a coordinated care plan that clearly outlined what steps should be taken to manage her care. The NP arranged for her blood work to be done and the social worker provided emotional support and arranged for the plan to be communicated to Anji in her own language.
Anji started taking her medication and following her care plan and was able to see a mental health professional through the Ontario Telemedicine Network (OTN).
Today, Anji is doing well. She is managing her diabetes through diet, medication and regular check-ups. She is better able to deal with her anxiety and knows where to go for help when she needs it. Her 14-year old daughter, Amina, is happy with the care and support her mom has received and says, “my mom no longer goes to the ER since becoming your patient.”
Primary care providers are an anchor for people within the broader health and social services system. They help people maintain healthy lifestyles, recover from acute health conditions and manage chronic disease through monitoring, system navigation, assistance, education and screening.
While the majority of Waterloo Wellington residents have a family doctor, there are some who do not. To address this gap, the Province introduced nurse practitioner lead clinics as a new delivery model for primary care.
In Waterloo Wellington, the WRNPLC operates out of two locations (Kitchener and Cambridge). Since 2012, the clinic has welcomed 2,865 residents into their primary care practice and continues to accept new patients.