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 2024-25

Our CSTI teams provide…

The Access Appointment ServiceOpen 365 days a year, the Access Appointment Service at our clinic, the Primary Care Centre, provides appointments for patients in immediate need.
Interdisciplinary teamsOur Dietitian Program, Physiotherapy Program, and Senior Services team provide specialized care related to nutrition; shoulder, hip, and knee pain; and for medically complex older adults. 

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.

Helping to fill gaps with new programs

Like the missing pieces to a puzzle, our new Dietitian Program and Physiotherapy Program are helping complete the health picture for more and more people at no cost to them. 

While they target different conditions, both programs focus on people who cannot afford physiotherapy or nutrition counselling and lack coverage from other sources — a serious barrier in these areas — to help take cost out of the equation. 

First, in spring 2024, we opened our Dietitian Program up to referrals from doctors in our membership for their patients in need of one-on-one dietitian support for conditions where it was not widely available (gut health, kidney health, and liver health). 

Once referred, eligible individuals meet virtually with one of our dietitians to discuss their goals, existing knowledge, and health and diet so they can work on a care plan together and receive the most appropriate type of care from our dietitians, our nurses, or an external program. Ninety per cent of patient survey responses rated their dietitian care as excellent or very good. 

A few months later, we started our Physiotherapy Program so members could refer their patients with rotator cuff-related shoulder pain or joint-related hip and/or knee pain due to osteoarthritis. These conditions were prioritized through engagement with doctors and an evidence and literature review to maximize results for referred patients within our resources. 

Referred, eligible individuals have a virtual assessment appointment with one of our physiotherapists to discuss their needs and then move on to the most appropriate care option: In-person physiotherapy, the GLA:D Hip and Knee Osteoarthritis program, or a referral to a community-based program.

Patients participating in the GLA:D program experienced improvements in pain, function, and quality of life at both the three- and 12-month follow-ups and 95 per cent of patients with shoulder pain experienced improvement. 

Our members highlighted the need for physiotherapy and dietitian support through a survey, interviews, and working groups that helped us develop these programs. 

Thank you to everyone involved. Monitoring and evaluation of the programs are ongoing and will support the identification of improvement opportunities.  

Learning, working together

Case rounds: Always learning, together

Throughout 2024-25, the nurses and pharmacist with our Senior Services program met in person for monthly case rounds focused on education, resource sharing, and presentations. 

The case rounds are flexible and included:  

  • Nurses presenting a recent patient case (while protecting the patient’s identity), followed by a roundtable discussion 
  • Presentations on medications from the pharmacist 
  • Doctors with the program attending to share guidance on cases or provide education 

The shared learning has also helped build understanding between the in-clinic team members and those who work remotely and do home visits. 

The team enjoys and benefits from the meetings, and it is another example of ongoing learning and improvement at our PCN. 

Clinic collaboration keeps appointments available

Continued collaboration between the Access Appointment Service at our clinic, the Primary Care Centre, and the Mosaic PCN and Calgary Foothills PCN access clinics helped meet challenges throughout the 2024-25 fiscal year: 

  • An increase in patients needing follow-up due to the challenges of patients finding a family doctor or gaining timely access to an appointment
  • The relocation of both the Mosaic PCN and Calgary Foothills access clinics
  • The yearly rise and fall of demand due to holidays and respiratory viruses like COVID-19 and the flu

The three PCN clinics work together to monitor the number of referrals they receive and the number of appointments available to manage the demand and get people a doctor’s appointment. 

The collaboration between the three urban PCNs and with Health Link (811) allows the clinics and Health Link to offer patients a choice in location and provide appointments even when one clinic is booked up. 

Our 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 refers a person in our area without a doctor or a member’s patient who called 811 in need of an appointment

The Access Appointment Service also accepts referrals from Rockyview General Hospital to help avoid unnecessary, additional hospital visits and for follow-up care when the person does not have a family doctor. 

Involving patients

Our Patient Advisory Council

Our Patient Advisory Council (PAC) continues to serve as an essential voice in shaping how we deliver care, ensuring that the patient’s perspective remains at the centre of what we do. Representing a wide range of backgrounds and lived experiences, PAC members help identify gaps and share insights that strengthen our services, programs, and communications. 

In 2024-25, we onboarded two new members, growing the council to a total of nine patient advisors. Recruitment is ongoing as we continue to expand the diversity and representation of our PAC.  

Throughout the year, the PAC: 

  • Provided feedback on our Patient Experience Survey, leading to improvements in accessibility for older adults (e.g., simplified language, fewer questions, emoji-based responses), expanded survey reach, new promotional materials like QR-coded business cards, and a recommendation to develop a visual summary of results. 
  • Reviewed plain language descriptions of our Patient’s Medical Home team roles for use on clinic websites; PAC feedback ensured the descriptions were understandable to all patients, and the updated content was distributed to members in July. 
  • Reviewed updates to our Patient Bill of Rights to ensure it reflected the principles of respect, accessibility, and patient-centred care; provided feedback on the Prescription to Get Active initiative; and reviewed updates to our Mental Health Program. 
  • Participated in a Diversity, Equity, Inclusion, and Belonging (DEIB) focus group facilitated by third-party experts, offering feedback on how our PCN’s programs, services, and policies could be more inclusive, plus a DEIB co-design session to support inclusive planning and decision-making. 
  • Met with Accreditation Canada surveyors during our evaluation process; the surveyors highlighted the PAC’s involvement as a strength, commending our commitment to integrating the patient voice.