Community Services, Transitions & Integration
Helping patients connect with care outside of their family doctor’s office is vital to their health.
Our teams support our CSTI priority by assisting the doctors in our membership and their patients in this journey with referral-based programs.
Highlights from 2023-24
Our CSTI teams provide…
CSTI also cultivated partnerships with health and social agencies to better connect community programs and doctors.
All the doctors in our membership can refer their patients to these programs. If a clinic is closed, Health Link (811) can refer patients to the Primary Care Centre.
Primary Care Centre: Boosting access
Our clinic, the Primary Care Centre, evolved and adapted throughout fiscal 2023-24 to better support patients and doctors in our membership while keeping pace with the same referral volume to its Access Appointment Service that set a record in 2022-23.
In 2023-24, the Primary Care Centre team:
- More than doubled their weekend and holiday hours — going from 1 – 4 p.m. to 9 a.m. – 4 p.m. — to increase the number of available appointments when many doctors’ offices are closed.
- Collaborated with the Medical Officer of Health to support the fall 2023 E. coli outbreak response in Calgary by reporting and tracking any patients linked to the outbreak seen at the clinic.
- Switched the clinic and our Senior Services team from Wolf EMR to the advanced, cloud-based Telus Collaborative Health Record (CHR) platform for electronic medical records ahead of the “retirement” of Wolf EMR.
The Access Appointment Service provides appointments every day of the year to people who need to be seen within 24 hours when:
- A doctor in our membership can’t see their patient within the time recommended and sends a referral.
- Health Link (811) refers a person in our area without a doctor or a member’s patient who called 811 in need of an appointment.
- A RhoGAM injection is required for Rh-negative mothers experiencing a bleeding event.
- A Tdap (Tetanus) vaccine is required for at-risk patients following an injury.
Not only did the referral volume remain high, but the clinic saw an increase in patients without a family doctor or experiencing difficulty accessing their family doctor in a reasonable time frame and patients with more complex health needs. The service is a vital alternative to walk-in clinics and ERs as the clinic faxes a visit summary to the patient’s doctor after the appointment so it is part of their records.
The Access Appointment Service also accepts referrals from Rockyview General Hospital and through a collaboration with clinics run by the Calgary Foothills PCN and the Mosaic PCN.
The collaboration between the three urban PCNs in Calgary and Health Link allows the clinics and Health Link to offer patients a choice in location and provide appointments even when one clinic is booked up.
Collaborating for convenient 24-hour blood pressure monitoring
Better connecting community programs and doctors is an area of focus for our PCN and the CSTI priority. In 2023-24, we collaborated with four service providers in Calgary to make their 24-hour blood pressure monitoring more accessible and convenient for the patients of our members (with no out-of-pocket cost for the patient).
Working together, we created a single referral form that all four providers would accept at their six local locations, making it easier for doctors to refer to the best location for their patient.
Twenty-four-hour blood pressure monitoring allows a device to measure your blood pressure at regular intervals as you move throughout a typical day, even while you sleep. People referred for monitoring are booked one appointment to be fitted with a monitor and then a second where it is removed. The results and a report and then sent to their doctor.
Why it matters:
- Some people who have normal blood pressure at home may have elevated blood pressure in a healthcare setting like their doctor’s office (white coat hypertension).
- It tracks the effects of medications people take throughout the day on their blood pressure.
Our Patient Advisory Council
Our Patient Advisory Council (PAC) continues to be an indispensable voice, representing the diverse demographics of the patients we serve. The community members who volunteer on the council help identify gaps in our programs and services through quarterly meetings and incorporate patient perspectives into our care.
In 2023-24, the PAC provided feedback on several programs and services, such as our:
- Dietitian Program and Physiotherapy Program that we launched in fiscal 2024-25 following their development through broad stakeholder engagement
- Mental Health Program
- Plain language project to simplify the language, structure, and organization of our content and communications
- CWC PCN Patient Bill of Rights
- Mission, vision, and values
PAC feedback was critical in shaping programs to better meet the needs of our patients by further enhancing our:
- Intake process so patients do not need to repeat their medical history multiple times
- Personalized care that considers patients’ financial circumstances to provide tailored advice
- Overall patient-centric approach, prioritizing accessibility, continuity of care, and adaptability
Expanding horizons:
With the aim to grow the PAC from six members to nine in 2024, we are not just increasing numbers — we are amplifying voices. Each new member brings a new perspective and lived experience to enrich our understanding and services.