Supporting high-quality, team-based care for 995 residents, across 11 long-term care homes in Abbotsford
Developed in partnership with Fraser Health and funded by the Family Practice Services Committee, Abbotsford Division of Family Practices’ Long-term Care (LTC) Initiative brings together physicians, care teams and leadership to provide coordinated, resident-centred care in LTC settings.
By building meaningful support systems for LTC physicians and teams, driven by a sustainable and collaborative care model, we aim to provide consistent, high-quality, and compassionate care for Abbotsford’s long-term care residents.
Our strategy
The LTC program is built on a team-based model that ensures residents receive ongoing, proactive, and responsive medical care.
Each resident is supported by a most responsible physician (MRP) who works closely with nurses, directors of care, and interdisciplinary teams within each care home. Through regular visits, medication reviews, and care planning, our LTC physicians are able to effectively respond to changes in residents’ health-care needs.
This collaborative approach supports:
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Continuity of care for residents
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Strong communication between physicians and care teams
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Timely clinical decision-making
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A more supportive environment for both residents and providers
24/7 physician coverage
Physicians participate in a shared on-call rotation that provides after-hours coverage across all LTC sites. This program ensures residents have access to care at all times, through a coordinated, community-wide on-call system.
A centralized answering service connects care teams directly with the on-call physician, enabling timely response to urgent needs and reducing unnecessary transfers to emergency departments.
Physician engagement
More than 30 physicians currently participate in the Abbotsford LTC program, working across multiple sites to provide high-quality resident care.
The Abbotsford Division supports LTC physicians in various ways:
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A structured team-based care model
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Leadership opportunities (physician leads and team leads)
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Access to continuing education, tools, and clinical resources
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Ongoing collaboration with facility leadership and Fraser Health
The program encourages meaningful physician involvement while maintaining flexibility and sustainability in practice.
Quality improvement and best practices
The Abbotsford LTC program is aligned with provincial best practices and focuses on continuous quality improvement.
Key priorities include:
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Proactive and preventative care
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Regular medication reviews and care conferences
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Reducing avoidable hospital transfers
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Enhancing resident and family experience
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Supporting education and knowledge sharing across care teams
