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.

Clinic Team Education Topics:

• Cultural Safety Talking Circles

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.  

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 Diabetes Basics program offered with RNs 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).

Poster:

• Discover Healthy Eating Group Program 

Registered Nurse (RN) 

Patient Group Education: 

These group education programs are available virtually across the region, and in person in Trail, Nelson, Castlegar, Kaslo, and Grand Forks.  Referrals to both these group programs can be made by using the PCN Regional Referral Form (please note the program name on the form).

Diabetes Basics (Led by the PCN regional RN and Dietitian)

• • • The session is intended for individuals who have recently had pre diabetic A1C and / or FBG flagged by their health care professional OR have recently been diagnosed with type 2 diabetes. 

    • This session is intended for stable clients who are able to initiate diet and exercise changes to help manage their diabetes.

    • This is not for individual diabetes management. The facilitators do not manage client’s medication or insulin.

    • Note: The Diabetes Education Centre (DEC) will continue to provide education and support for those who require education beyond the Diabetes Basics program. Referrals sent to the DEC that can be supported by the Diabetes Basics program will be redirected to the Primary Care regional team.

Diabetes Basics 2025 Schedule

Advance Care Planning 

• • The class is a single session, facilitated by the KB Primary Care Network Regional Registered Nurses. The intended audience is individuals and family members who would benefit from and are interested in developing an Advance Care Plan. 1:1 follow up support is available to help further navigate the process if required. Patients can also self-refer by calling 250-365-4337.

  • Topics covered include:  

• The process, benefits, and limitations of Advance Care Planning.

• The importance of discussing Advance Care Plans with family, loved ones, and the primary care provider.

• Information on documents and resources to support Advance Care Planning.

Advance Care Planning 2025 Schedule

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 and patients can also self refer by calling 250-608-4869. 

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:

  • Guide to referring to OT Services

  • PCN Occupational Therapy Info Sheet

• Trail, Beaver Valley and Rossland resources:

  • Guide to referring to OT Services

  • PCN Occupational Therapy Info Sheet

Social Worker (SW) - Supporting Noted Clinic Sites