Community Services, Transitions & Integrations

Helping patients connect with care outside of their family doctor’s office is vital to their health.

Our CSTI department assists physician members and their patients in this journey with referral-based programs.

Highlights from 2021-22

Our CSTI team provides…

The Primary Care CentreOpen 365 days a year, the Primary Care Centre provides appointments for patients in immediate need.
Social WorkersThe CWC PCN’s Social Worker team helps people of all ages access social services and navigate the healthcare system.
Senior ServicesOur interdisciplinary Senior Services team provides specialized primary care for medically complex seniors.

CSTI also cultivated partnerships with health and social agencies, like Community Connect YYC, to better connect community programs and physicians.

All CWC PCN physician members can refer their patients to these programs. If a clinic is closed, Health Link (811) can refer patients to the Primary Care Centre.

Meeting the increased need

The Primary Care Centre was busier during the second year of the pandemic than the first as the already-high number of referred patients in need rose in the winter.

The clinic continued to play a critical role in responding to the pandemic while also seeing patients referred for other health needs by physician members, Health Link, and Rockyview General Hospital.

When patients couldn’t get in to see their family doctor but needed help within 24 hours, their doctor or Health Link could refer them to our clinic’s Access Appointment Service. The Primary Care Centre team would call the patient, schedule an appointment, and fax the results to the individual’s doctor.

Until testing criteria changed in the fall, the clinic also supported patients who tested positive for COVID-19 but did not have a family doctor and were referred by Alberta’s Medical Officer of Health.

These referrals wound down in September, but referrals from physician members and Health Link increased.

The Primary Care Centre team rose to the challenges by:

  • Increasing the number of doctors and nurses on site
  • Maintaining their enhanced safety protocols
  • Leveraging their collaboration with clinics run by Calgary Foothills PCN and Mosaic PCN

In August 2021, the three PCNs began a project to offer patients a choice of three PCN-run clinics for an appointment within 24 hours if the first clinic’s location was inconvenient. They were also able to use the collaboration to arrange appointments at the other clinics if one clinic ran out of openings.

It was an expansion of a project begun in 2020 when Health Link began offering callers a choice of the three clinics. The clinics all fax visit information to the patient’s family doctor after the appointment to keep them informed.

Supporting the most vulnerable

Supporting seniors

Demand remained high for our Senior Services team, who assisted referred elderly patients through home visits, virtual appointments, and in-person appointments at the Primary Care Centre.

The interdisciplinary team completed in-depth assessments, played a vital role as advocates for isolated patients, and helped patients and their families navigate the healthcare system and supports in the community.

Specializing in elderly care, Senior Services works collaboratively with the referring family doctor, providing patient assessments for memory, functional ability, safety, nutrition, and medications.

Homebound seniors were also supported by our Seniors Home Based Care program. Working collaboratively with AHS’s Home Care, the program helped otherwise isolated seniors with home visits by a physician and nurse.

Social Workers needed more than ever

Our Social Workers were busier than ever in the second year of the pandemic, helping patients with even greater complexity than last year.

Multiple factors contributed to the increase, with mental health, financial issues, employment support, and different health benefit issues acting as the primary drivers.

Additionally, some people who received the Canada Emergency Response Benefit or the Canada Recovery Benefit no longer met the criteria for services that they had previously accessed. Others were impacted by the changing economy, increasing cost of living, or changes to support that had once been in place.

Our Social Worker advocated for required services, located and negotiated potential resources, and navigated complex social systems, addressing structural and larger systems barriers for patients.

There when you needed us

In 2021-22, we held


appointments at the Primary Care Centre


appointments with seniors in the Calgary community

Patient Advisory Council (PAC)

Involving patients in our work

Our Patient Advisory Council helps us put patients at the centre of our work by sharing the perspectives of patients and families at regular meetings.

Five volunteers from the community make up the council along with CWC PCN employees, our Medical Director, and a member of our Board.

In 2021-22, the council provided feedback on multiple areas, such as virtual care, online public engagement, and our new 2022-25 business plan.

Overall, the council contributes to our PCN by:

  • Providing meaningful input into the review of our programs, services, and policies
  • Identifying where gaps may exist in program delivery for patients with diverse cultural backgrounds, religious beliefs, and care needs
  • Conducting an annual review of our Patient Bill of Rights and Responsibilities
  • Reviewing patient-facing communications and providing quality-oriented feedback