PCN Regional Hub

All PCN clinics are encouraged to refer patients to the following regional professionals on an ongoing basis. The PCN regional positions are a crucial way for PCN clinics to enhance their patient attachment capacity. 

Aboriginal Health Coordinators (AHC)

Priority Referrals:

• Clients who do not currently have wrap-around support and/or who are not accessing healthcare services.

• Must be self-identifying as Indigenous (status or non-status First Nations, Métis, Inuit).

Services:

• Support to access and navigate FNHA benefits and other indigenous-specific funding and resources.

• 1:1 support based on client directed needs and goals. This can include:

  • Traditional and cultural wellness support.

  • Assistance to navigate the healthcare system.

  • Closely support clients who have an aversion to accessing the healthcare system, this could include attending appointments with them until they feel safe to do so independently.  

  • Help to attach to a family doctor, nurse practitioner, other health professionals.

  • Community service referrals.

  • Advocacy support.

• Staff education (on request).

• Collaboration with staff - cultural safety consults.

Posters:

• General Services

• West Kootenay

• Boundary

Clinical Pharmacist

Requirements to access PCN Pharmacy:

• Before accessing PCN Clinical Pharmacist services, all clinics must arrange EMR access and a clinic provider meeting with the Pharmacist.

Available services:

• Polypharmacy review and deprescribing recommendations

• Provide comprehensive medication management* and education for complex patients

• Shared decision making about a possible medication change

• Assessing medication adjustments after hospital discharge 

• Reconcile medication history

• Identify drug-therapy problems and recommend changes to medications

• Patient education and adherence strategies

• Participate in patient care rounds / care conferences

*comprehensive medication management  includes an individualized care plan that ensures medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other prescribed medications, and able to be taken as intended by the patient

Complete referrals:

• Only complete referrals will be accepted. Please include up-to-date patient contact information and a description of the specific service(s) needed, including whether the patient needs to be seen urgently. This will enable the Pharmacist to triage referrals appropriately.

Questions:

• If you have questions or need clarification about PCN Pharmacy services, please reach out to the Pharmacist directly.  

📌 Referral Tips:

These simple steps can help Pharmacists provide the most effective support possible: 

✅ Include patient-specific information
Provide relevant clinical details and context with your referral. General drug therapy questions without patient-specific information are not recommended.

✅ Prepare patients for the referral
Ensure patients are aware of the referral and understand the importance of attending their appointment or cancelling in advance if needed.

✅ Include complete referral information
Provide clear, goal-directed details to guide the pharmacist's assessment and support efficient, targeted interventions. (For example, if "polypharmacy" or "medication review" is the reason for referral, specify the intended focus—such as deprescribing a PPI, reducing sedative burden, or optimizing therapy for a specific condition.)

Registered Dietitian (RD)

Priority Referrals – Support across the lifespan:

• Healthy eating & lifestyle.

• Pre/postnatal nutrition.

• Healthy eating for children and families.

• Food insecurity support/access to community food resources

• Food allergies/intolerances

• Chronic disease management (Pre-DM, Cardiovascular disease).

• Gastrointestinal disorders.

• Recovery & preparation for surgery.

• Malnutrition/FTT, vitamin & mineral deficiencies.

• Palliative care.

Services:

• Patient group education (see below) and staff education (on request).

• Collaboration with staff - complex clients, connecting clients with resources, specific practice questions.

• 1:1 client assessment and intervention.

• Development of resources (such as handouts).

Group Education:

• Nutrition for Well-being | Diabetes Basics | Heart Health | Check out Full Details kbpcn.ca/group-education >

📌 Referral Tips:

These simple steps can help RDs provide the most effective support possible:

✅ Include relevant clinical information
Include the reason for referral, along with any relevant medical history, lab values, and medications. For patients with prediabetes, it is helpful to include their A1C and any antihyperglycemic medications.

✅ Refer for the diagnosis or condition
Dietitians assess nutrition habits and recommend evidence-based interventions tailored to each patient. Referring for the diagnosis rather than a specific diet helps avoid unnecessary food restrictions.

✅ Support sustainable nutrition changes
Dietitians focus on building long-term nutrition and behaviour skills rather than providing rigid meal plans.

✅ Let patients know about group education options
Patients may be offered a group class before scheduling an individual appointment with a Dietitian. If group education is not appropriate, please indicate this on the referral.

Registered Nurse (RN) 

Group Education: 

Diabetes Basics, Advance Care Planning, Health Literacy, Heart Health

These group education programs are available virtually across the region, and in person in Trail, Nelson, Castlegar, Kaslo, and Grand Forks.  

Check out Full Details kbpcn.ca/group-education >

Referrals to these group programs can be made by using the PCN Regional Referral Form (please note the program name on the form).

Respiratory Therapist (RT)

The most effective way to use the PCN RT services is to focus on referrals early on in the disease trajectory.

Priority Referrals:

1. Airway disease (COPD, asthma, bronchiectasis)

   • New diagnosis, including children

   • Recent exacerbation

   • Active symptoms

   • Inhaler management and barriers

   • Discharge follow up

2. Tobacco Dependence Counseling

Services:

• 1:1 virtual follow up, does not include diagnostic testing

• Support for clinic team members

  • Navigating respiratory services in KB

  • Specific practice questions

Patient Group Education:

• “Better Breather’s” Zoom Group for anyone with any chronic lung disease. The Better Breather’s group meets weekly, Wednesday’s at 10am via ZOOM. Refer your patients using the PCN referral form, Check out full details here: kbpcn.ca/group-education >

Occupational Therapist (OT) - Nelson and Trail CHSAs only

Referral Requirements:

• Before accessing PCN OT services, all clinics must arrange EMR access and a clinic provider meeting with the OT.

• Nelson & Salmo resources:

  • PCN Occupational Therapy Info Sheet

• Trail, Beaver Valley and Rossland resources:

  • Guide to referring to OT Services

  • PCN Occupational Therapy Info Sheet

Patient Group Education:

• STEP UP Falls Prevention for Nelson, Trail, Salmo area patients: Check out the poster for details > Refer your patients using the PCN referral form.

📌 Referral Guidance: Return-to-Work Support

Patients with Short-Term Disability (STD), Long-Term Disability (LTD), ICBC, or WorkSafe claims often have access to occupational therapy services through their benefit plans. These services may include workplace assessments, functional capacity evaluations, and graduated return-to-work (GRTW) plans and support.

While PCN Occupational Therapists (OT) can provide short-term “bridging” support during the early stages of recovery, they don't develop or manage full GRTW programs.

🚩 To avoid impacting access to insurer-funded OT services, providers should not indicate that a patient is receiving PCN OT services for return-to-work support, as this may lead insurers to deny OT services available through the patient's disability plan. Read more in the guidance document >