Team-Based Care Program

The Team-Based Care Program works with our member physicians to provide support to patients with a variety of concerns. We have healthcare team members working both in our central Leduc office and within some of our clinics. Registered nurses, registered dietitians, an exercise specialist, behavioural health consultants, and mental health therapists support patients through their health journey. A referral from your family doctor is required to access these providers and services.

Click each provider type below to see how they can support your health journey:

Registered Dietitians

Registered Dietitians (RDs) work with patients with chronic conditions and promote healthy eating in various population groups. Patients are provided with nutrition assessment, education, and support for behaviour change.

Nutrition-related conditions – Dietitians can help with the following conditions:

  • anemia (iron deficiency) and other nutrient deficiencies
  • digestive disorders such as Irritable Bowel Syndrome, Celiac Disease, Crohn’s Disease
  • food allergies and intolerances
  • malnutrition or underweight
  • non-Alcoholic Fatty Liver Disease
  • pediatric nutrition concerns such as picky eating for children ages 2-17
  • improving diet quality
  • vegetarian and vegan diets
  • prenatal and postpartum nutrition

Nutrition counselling for chronic conditions:

  • diabetes and pre-diabetes
  • high cholesterol and high blood pressure
  • heart disease
  • obesity

Working individually with a dietitian involves an initial 60-minute appointment to review your current eating habits.  The RD will work to determine your personal goals and use a non-dieting approach to help make sustainable and realistic changes.

Currently, we have 2 Registered Dietitians working at the centralized Leduc PCN office.

To access the services of a Registered Dietitian, please talk to your family doctor.

Exercise Specialist

The Exercise Specialist will accept requests to work with patients to assess current abilities, provide education around the importance of exercise and provide a program specific to the individual health concerns of the patient. Working individually with an Exercise Specialist involves a 60-minute appointment that includes gathering patient health history, discussing goals for treatment, and coming up with a treatment plan to address identified goals. Physical assessments may be necessary to help identify starting points for treatment and appropriate exercise prescription. The focus of the treatment is to help patients better understand and self-manage their health conditions

The Exercise Specialist can help with the following conditions:

  • Balance/coordination problems
  • Chronic pain (fibromyalgia, rheumatoid arthritis, previous traumatic injuries etc.)
  • Chronic soft tissue injuries (rotator cuff tear, tendinopathy, recurring muscle strain)
  • Deconditioning/sedentary lifestyle
  • Osteoarthritis
  • Osteoporosis/osteopenia
  • Pre-surgical rehabilitation for joint replacements
  • Post-surgical rehab from joint replacement (post-physiotherapy)

Our Exercise Specialist is certified to offer the GLA:D Canada Hip and Knee 8-week education and exercise program for those with stiff and/or painful knees and/or hips, or those with knee and/or hip osteoarthritis, as well as GLA:D Back for those with persistent or recurrent low back pain. GLA:D stands for Good Life with osteoArthritis: Denmark. 

The Exercise Specialist works at the centralized Leduc PCN office; to access the services of our Exercise Specialist, please talk to your family doctor.

Our PCN YouTube channel offers a series of home workouts that take anywhere from 5 minutes to 30 minutes to complete; these can be accessed anytime.

Behavioural Health Consultants

The Behavioural Health Consultant (BHC) primarily focuses on behavioural health strategies and interventions to assist patients improve their day-to-day functioning. BHCs, both within physician clinics and at the central office, work with patients of all ages. In addition, the BHCs will assess the need for additional support and refer when appropriate to PCN Mental Health Therapists or navigate, refer or provide information for the patient to community resources more suitable in treating their needs.

BHCs can help with the following conditions:

  • Depression and anxiety
  • Post-traumatic stress effects
  • Substance use
  • Family/relationship/parenting issues
  • Stress/occupational stress
  • Grief
  • Self-esteem
  • Anger
  • Chronic pain
  • Sleep issues
  • Weight management
  • Irritable Bowel Syndrome
  • Tobacco Cessation
  • Chronic Disease Management

Most BHC appointments are up to 30 minutes in length. You will be asked about physical symptoms, emotional concerns, behaviours, and how these affect your day-to-day functioning. If needed, the BHC will work with you and your health team to create a treatment plan and arrange a follow-up appointment.

Currently, we have Behavioural Health Consultants working at the centralized Leduc PCN office as well as in the following member clinics:

  • Griffiths Clinic (Leduc)
  • Beaumont Medical Clinic (Beaumont)
  • Devon Medical Clinic (Devon)
  • Willow Family Medicine (Edmonton)

To access the services of a Behavioural Health Consultant, please talk to your family doctor.

Mental Health Therapists

The LBD PCN Mental Health Therapist provides brief psychotherapy to patients who present with mild to moderate emotional or psychological issues. This is done through an initial screening by the Behavioral Health Consultant; the patient is then seen by the Mental Health Therapist who will offer guidance and support to implement new skills to address utilizing evidence-based techniques.

Together, the Mental Health Therapist and patient will come up with an agreed treatment plan to address emotional and mental health. For continuity of care, the Mental Health Therapist will provide a treatment summary identifying presenting issues identified with the patient, treatment plan and outcome, clinical impressions, and future recommendations back to the referring physician.

The Mental Health Therapists work at the centralized Leduc PCN office; in order to access the services of a Mental Health Therapist, please talk to your family doctor.

Social Worker

The Social Worker will provide comprehensive social work services to patients within the Leduc Beaumont Devon Primary Care Network.

The Social Worker will assess, plan, implement, and evaluate social work care plans for patients who require direct practical supports. The Social Worker will assist patients in accessing financial supports, housing, employment opportunities, and other resources to improve the patient’s quality of life.

The Social Worker can support those with the following concerns:

Domestic/Interpersonal Violence
Career and Education
Disability Support
Family Support
Food Insecurity
Housing and Shelter
Income Support
Legal Services
Leisure and Recreation
LGBTQ2S+ Resources
Medication Advocacy
Senior Support
Substance Use

Registered Nurses

Registered Nurses:

The Registered Nurses in the Team-Based Care program provide a range of primary care nursing services both in our physician clinics as well as the PCN central office. Our RNs are involved in health promotion activities and chronic disease management.

Diabetes Focus

Our nurses provide education and support, and insulin counselling to patients with diabetes, including those who have been newly diagnosed and patients who are at risk of developing the disease (pre-diabetes).

Patients receive:

  • generalized lifestyle teaching
  • blood sugar control/stabilization
  • initiation and titration of insulin (with physician approval)
  • diabetes foot assessments

Other services include:

  • respiratory management (Asthma/COPD)
  • obesity management goals and support
  • disease-prevention and screening
  • cholesterol management
  • promote healthy lifestyles, create care plans, and provide education
  • blood pressure testing, monitoring, and education
  • memory testing
  • oral medication management with physician approval
  • explain lab work or other test results and assist with filling out forms when needed
  • injections
  • smoking cessation coping strategies and resources
  • internal referrals to other PCN clinicians (Dietitian, Behavioural Health, Exercise Specialist)
  • cervical screening (in specific member clinics)

Currently, we have Registered Nurses working at the centralized Leduc PCN office as well as in the following member clinics:

  • Griffiths Clinic (Leduc)
  • Beaumont Medical (Beaumont)
  • Hospital Medical Clinic (Devon)
  • Devon Medical Clinic (Devon)
  • Walker Lake Family Clinic (Edmonton)
  • Thorsby Nurse Practitioner Clinic (Thorsby)
  • Warburg Nurse Practitioner Clinic (Warburg)

To access the services of a Registered Nurse, please talk to your family doctor.

Licensed Practical Nurses

Licensed Practical Nurses (LPNs) working in the LBD PCN provide support in the following areas:

  • They work as part of the team in the family physicians office (Patient’s Medical Home);
  • They perform procedures such as dressing changes, ear syringing, wart treatment;
  • They provide preventative health screening;
  • They also provide education to patients on various health conditions.

We currently have LPNs working at the following member clinics:

  • Beaumont Medical Clinic
  • Smyth Associate Clinic

To access any of our Team-Based Care healthcare professionals, please talk to your PCN family doctor or nurse practitioner.

For detailed information on each of our health care providers, please click on the provider title above.