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 2025-26
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.
Supporting more physiotherapy, dietitian patients
At our PCN, the start of a program is the beginning — not the end — as we monitor and evaluate all our programs to enhance care.
So, after carefully watching program capacity, we expanded eligibility for our two newest programs in this last fiscal year to support more patients with our:
- Dietitian Program starting to help people with polycystic ovary syndrome (PCOS)
- Physiotherapy Program beginning to help people with chronic low back pain
Low back pain is the leading cause of years lived with disability worldwide, and everyone with PCOS can benefit from nutrition counselling. Doctors had also highlighted that these conditions needed more support than what was available.
Our programs do not charge people. So, because of the changes, patients of our membership who do not have coverage and cannot afford physiotherapy or nutrition counselling have a no-cost option for two more conditions. Both programs expertly assess referred, eligible patients to discuss their needs and connect them with the most appropriate care option:
- Dietitian Program services for people with gut health, kidney health, liver health, or PCOS issues include additional appointments with our dietitians or nurses, self-management resources, or a referral to an external service.
- Physiotherapy Program services for people with persistent chronic low back pain, rotator cuff-related shoulder pain, or joint-related hip and/or knee pain due to osteoarthritis include in-person physiotherapy, the GLA:D Hip and Knee Osteoarthritis program, the GLA:D Back program, exercise-based rehabilitation plan, or a referral to an external service.
Thank you to everyone who helped us provide more support through these programs.
Primary Care Centre: Information
and appointments when needed
Our clinic, the Primary Care Centre, ended the 2025-26 fiscal year by connecting its electronic medical record (EMR) system
to the provincial platform for sharing information across a patient’s care team through Alberta Netcare.
Now, select information from appointments with our clinic’s Access Appointment Service and Senior Assessment Clinic (part of our Senior Services team) is more readily available for health professionals helping the patients our clinic also supported.
Our Primary Care Centre team also:
- Enrolled in Tarrant Viral Watch to contribute to our provincial, national, and international picture of influenza-like activity.
- Helped support people affected or potentially affected by the rise of measles, the Saskatoon Farm E. coli outbreak, and the cases of avian flu at Butterfield Acres.
- Continued to collaborate with the Calgary Foothills PCN and Mosaic PCN access clinics so people who needed an appointment and couldn’t see their doctor in time received care.
Our Access Appointment Service provides appointments every day of the year for 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 collaboration between the three urban Calgary PCNs and with Health Link (811) allows the clinics and Health Link to offer patients a choice of locations and provide appointments even when one clinic is booked up.
Our 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.
Senior Services improvements
Even before connecting their EMR to share information through to Netcare, our Senior Services built on past efforts with new improvements to:
- Improve communications with the two external services that sometimes receive referrals for the same older adults as our team
- Revamp their process of preparing information for Senior Services’ multidisciplinary, clinic-based team (our Senior Assessment Clinic) so that the doctors had the information they needed efficiently
- Streamline the booking of follow-up appointments with the program while the patient is still in clinic
For improved communication and coordination, the registered nurse (RN) and clinic coordinator with the clinic-based team now meet regularly with the clinical practice leads for our Social Workers and for our Senior Services’ RNs who work remotely and in the community.
Together, they review referrals to move patients to the most appropriate type of care, improving team communication and services for patients with wraparound care. They also identify when patients were referred to the two external services in addition to our program, and our clinic-based RN reaches out to contacts to reduce duplication of services and patient appointments and confusion.