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