Complex Care:
Referral Service: To improve the referral
process to specialists.
Long Term Care (LTC): Nurses and physicians round to
complete assessments, medication reviews and coordinate care in designated
facilities
Fall Prevention: Nurses identify and provide services to at risk
seniors
Goal: Timely coordination of care and referrals, increased
communication between all service providers
Chronic Disease:
Allied Health Team:
Nurses, dietitians and wellness coordinators provide services in all
clinics
Goal: Better management of chronic disease, enhanced continuity of
care, improved population health focus, improved access and earlier
interventions
Public Health:
Our focus is to improve the emphasis on
health promotion and disease prevention, liaison with existing community
programs, provide health and wellness information. We advocate healthy
lifestyles – activity, diet, self management, tobacco cessation
Goal:
increased wellness activities that promote health, increased public knowledge
and education associated with healthy living and disease prevention
Obstetrics:
The program promotes shared coverage by
physicians for obstetrics patients and ensures coordination of obstetrics
services
Goal: coordination of services to ensure continuity of care for
obstetrics patients
Mental Health:
Improve and coordinate access to mental
health services, education and support groups
Goal: strengthen and leverage
partnerships with services to maximize quality of care, patient access and
support
Communication and Education:
Ensure interconnectivity
between physicians, their offices, staff and patients
Goal: establish clear
and efficient communication pathways with all health care providers and
patients, to identify and access education for patients, physicians and PCN
staff to ensure knowledge and skills are current and transferable