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.

These team members provide support in these areas:

Registered Dietitians

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

Weight management assessment: RD’s in the central program provides patients with a comprehensive weight assessment that addresses the factors that contribute to obesity. RD’s may continue to see a patient for ongoing support or recommend referral to other team members or agencies.

Nutrition-related conditions: Referrals can be made to the RD’s for a variety of nutrition-related conditions throughout the lifespan. Patients may be directed to group sessions for healthy eating or seen on an individual basis depending on the concern. Dietitians may work with patients for a short time e.g. 1 or 2 visits and then determine if care can better be provided by another agency. Patients requiring long-term self-management support may work with the dietitian for up to 6 months.

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

  • Hospital Medical Clinic (Devon)
  • Associated Medical Clinic (Devon)

In order 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. Individual or group options can be requested.

Supervised group exercise program: Patients referred to group exercise programs will be assessed and placed in a group program for up to 8 sessions. Patients suitable for the group include those with chronic conditions who may need some additional support to get active.

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

Our Exercise Specialist, Adrien, has created a series of home workouts that take anywhere from 5 minutes to 30 minutes to complete. Hosted on our PCN YouTube channel, these can be accessed at any time.

Behavioural Health Consultants

The role of Behavioural Health Consultant (BHC) is primarily to focus on behavioural modification to achieve improvement in a patient’s physical, emotional or mental health issue. The BHC’s interventions are brief but occur more frequently to achieve behavioural changes with support. All BHCs both within physician clinics and at the centralized PCN office will see children with their parents, youth, adults and seniors. In addition, the BHCs will assess the need for psychotherapy and refer when appropriate to PCN Mental Health Therapists or navigate and refer the patient to community resources more suitable in treating their needs.

Behavioural Health Consultants working in physician’s office will comply with clinic standards in respect to patient charting and record keeping. For continuity of care and in the patient’s chart (EMR), a brief summary of the interventions, treatment and referrals provided by the BHC. The BHCs that are in the centralized office at the PCN are committed to achieving best practices in communication standards for continuity of care. Physicians will be notified of the outcome to their referral (i.e. appointment booked, declined, etc.) and a summary of the interventions, treatment and coordination of care both to community resources and within the Team-Base Care Program.

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)
  • Hospital Medical Clinic (Devon)
  • Associated Medical Clinic (Devon
  • Devon Medical Clinic (Devon)
  • Willow Family Medicine (Edmonton)

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

Mental Health Therapists

PCN Mental Health Therapists provide 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 the 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.

Registered Nurses

The Registered Nurses in the TBC program will assess, educate and support patients with or at risk of chronic disease. As a goal of our program is to promote patient self-management, our centralized RN’s will aim to work with CDM patients for up to 6 months to support self-management skills.

Diabetes Education: Assessment of adult patients with type 2 diabetes. Self-management education will be offered in individual and group settings.

Pre-diabetes education: Assisting patients diagnosed with pre-diabetes to adopt healthy behaviours to reduce the risk of developing diabetes.

Insulin start: RNs will assist patients in starting insulin under the direction of the PCN referring physician.  Patients with complex needs may be navigated to other agencies.

COPD education: RNs will assess patients with COPD and provide basic education with a focus on action planning to prevent exacerbations. More complex patients will be encouraged to attend the pulmonary rehabilitation program at the Leduc Community Hospital or another location in Edmonton.

Asthma education: RNs will assess patients with asthma and provide self-management support and education. This service will be available for patients aged 6 and over.

Hypertension: Lifestyle and self-management education will be provided as appropriate.

Dyslipidemia: RNs will assess lifestyle factors related to dyslipidemia and provide self-management education and support.

Tobacco Cessation: RNs can support patients with tobacco reduction and cessation through counselling and referral to community programs.

Diabetes foot assessment: The RNs will provide a foot assessment for patients with diabetes. Referral may be made to the high-risk foot clinic.

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)

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

Licensed Practical Nurses

Licensed Practical Nurses (LPN) 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.