TEAM-BASED CARE
How We Help Patients
As a Primary Care Network (PCN), our programs and services are designed to help our members — doctors who join our PCN — meet the health needs of their patients at no cost to doctor or patient.
All our programs and services require a doctor’s referral.
Talk to your doctor about what programs and services they can access that may be of benefit to your health and well-being.
Please visit our directory to see if your doctor is part of our PCN or search Alberta Find a Doctor’s provincewide doctor directory to find your doctor’s PCN.
Our goal is to strengthen people’s medical homes with team-based care from our clinic and regulated health professionals in partnership with family doctors. Our clinic, the Primary Care Centre, offers a referral-based appointment service with extended hours for people who need to see a doctor within 24 hours but can’t get an appointment with their doctor or don’t have a doctor and live in our area.
To further support doctors and their patients, our Patient Care Coordinators and Health Information Coordinators assist with proactive health screening based on best practice guidelines and coordinating chronic disease management.
If your doctor is one of our members, they may refer you to our clinic or for help from our:
- Primary Care Registered Nurses
- Primary Care Registered Psychologists
- Social Workers
- Senior Services Team
- Primary Care Registered Dietitians
- Physiotherapists
Primary Care Registered Nurses
Using their extensive knowledge and skills, our Primary Care Registered Nurses deliver patient-centred care, review condition-specific education, and provide encouragement so you can better play an active role in your health. Your nurse will work closely with your doctor and other members of your care team to help you work toward your health goals.
Our Primary Care Registered Nurses are trained in many areas related to chronic disease and can support you with:
- Hypertension and heart health
- Diabetes, obesity, and weight management
- COPD, asthma, and smoking cessation
- Various gastrointestinal issues
- Prenatal care and education
- Many other conditions, including mental health concerns
Primary Care Registered Psychologists
Once referred, you’ll start with a 30-minute phone appointment with one of our Registered Psychologists to discuss your needs and help you find the right supports. This psychologist will provide you with self-management ideas and, depending on your preference, might also include:
- Help with navigating community-based supports
- Booking an initial appointment for therapy with your clinic’s assigned Primary Care Registered Psychologist
Our Primary Care Registered Psychologists offer short-term individual therapy services and can treat a wide range of mental health needs including:
- Substance use, emotion management/regulation
- Anxiety, depression, stress, grief or loss, trauma
- Life transitions, personal growth, relationships
If you decide you want to work with your Primary Care Registered Psychologist, they will first help you identify your goals for therapy. Depending on your needs, you may gain tools for creating change, building resiliency, and coping.
Senior Services Team
Our specialized Senior Services team provides integrated, team-based care to older adults (65 years of age or older or physiologically aged) with medical issues. The comprehensive team provides access to physicians, geriatric psychiatry, pharmacy, social work, and nurses certified in seniors health.
Senior Services can:
- Complete in-depth assessments that may include cognitive screening, functional assessment, environmental risk, medication review, and fall or nutrition assessments
- Play a vital role as an advocate for patient and caregiver
- Provide recognition and support for those isolated or at risk of isolation
- Expertly navigate healthcare and community support systems
Primary Care Registered Dietitians
Our Primary Care Registered Dietitians work with patients to determine the most suitable care plan for their individual health needs and goals. They provide expert nutrition guidance and practical advice so patients can take control of their nutritional health.
Once referred, you’ll start with a one-hour appointment with one of our Primary Care Registered Dietitians so they can understand your goals, existing knowledge, and the factors influencing your health and diet.
Using their expertise, they will work with you to create a care plan:
- Continued one-on-one appointment(s) with the Primary Care Registered Dietitian for expert guidance and advice
- Referral to an AHS or community-based service or provide you with self-management resources
- Referral to one of our Primary Care Registered Nurses
Physiotherapists
Once referred, you’ll start with a 30-minute virtual appointment (or phone call) with one of our Physiotherapists to discuss your needs in greater detail. Together, you will determine the most appropriate type of care for you going forward.
In this consultation appointment, you will share your needs and goals as they relate to your referral with the Physiotherapist who will then explain program options to you and the next steps, depending on the agreed upon care plan:
- One-on-one, in-person physiotherapy appointments
- The in-person, group GLA:D Hip and Knee Osteoarthritis program
- An exercise-based rehabilitation plan developed by the Physiotherapist with you for self-management (and the Physiotherapist will follow up with you virtually in the future)
- Referral to an AHS or community-based program (e.g., Alberta Health Living Program, etc.)
