Nursing Program
The Calgary West Central Primary Care Network (CWC PCN) has a dedicated Nursing Program that works to support patients in our community. This resource page discusses the components of the Nursing Program and how it contributes to the overall well-being of those we serve.
Introducing the program
The CWC PCN is a non-profit organization committed to supporting family doctors and their patients. Our PCN has approximately 475 doctors in its membership, making it one of the largest PCNs in Calgary.
The CWC PCN’s Nursing Program helps us achieve our goal of supporting primary care in our community by offering many kinds of support to patients with different health issues. Our nurses help patients manage long-term conditions, make healthy lifestyle changes, access services for seniors, and much more. Right now, we have more than 30 nurses working in this in-demand program to help our doctors and their patients.
Program components
Our Nursing Program uses a patient-centred approach to care that encourages patients to be actively involved in their wellness journey.
This care can be divided into four distinct areas of focus within our PCN:
Our Primary Care Registered Nurses (PCRNs) are assigned to clinics to support referred patients with various chronic (long-term) conditions. This could include weight management support, diabetes management, heart health, respiratory conditions, and much more. The primary goal of our PCRNs is to support their patients’ overall wellness in an inclusive and understanding way that takes into consideration their unique circumstances and needs. This support falls under our Chronic Disease Management Program — a crucial part of our mission to support patients within our community. As of March 2023, our PCN panel (patients of our members) includes:
- 41,000 patients with asthma
- 12,000 patients with chronic kidney disease
- 23,000 patients with diabetes
- 38,000 patients with hypertension
- 15,000 patients with coronary artery disease
Many of these patients require ongoing support to properly manage their conditions. A doctor in our membership may refer a patient to a PCRN to help monitor and manage their chronic disease.
The support offered by our PCRNs is tailored to fit the needs of each patient. They can offer education and medical advice relating to the patient’s condition as well as emotional and motivational support to help them navigate their health journey.
As part of the Chronic Disease Management Program, PCRNs also support clinics with chronic disease screening and prevention projects that help ensure conditions are identified and managed as early as possible. By working to prevent and manage chronic diseases, our PCRNs assist in keeping patients from developing serious complications that could reduce their quality of life.
From April 2023 to March 2024, our PCRNs provided 15,504 appointments, with the top five reasons for referral being:
for diabetes concerns
for nutrition support
for weight management support
for medication management support
for pre-diabetes concerns
Our Senior Services’ Registered Nurses make up a specialized team that works to support senior patients. While PCRNs are assigned to specific member clinics, our Senior Services RNs operate collectively to serve all referred patients on an as-needed basis.
They may visit the patient in-person to perform home assessments, assist with referrals to community resources, and assess any changes to memory or cognition. They can also support patients in accessing home care or other services that can improve their quality of life.
Virtual appointments may also be used if they are a good fit for the patient. Caregiver assistance is also frequently provided to ensure everyone within the patient’s circle of care is informed and supported.
Senior Services Registered Nurse appointments from April 2023 to March 2024
The Senior Assessment Clinic, operating out of our Primary Care Centre, includes a Senior Services RN, licensed practical nurse, pharmacist, and doctor. This specialized clinic team works together to support senior patients with complex medical concerns. Their primary focus is to diagnose, treat, and support patients with dementia and other senior-specific illnesses. Caregivers are invited to attend these appointments so they can also gain valuable information and support from the team.
Each member of the team plays a key role on this team, with the Senior Services RN often providing ongoing support for the patient as they navigate their new diagnosis. The Senior Services RN will work closely with the doctor and pharmacist to determine a care and medication plan for the patient.
Both PCRNs and Senior Services RNs can help make referrals to the Senior Assessment Clinic for patients who need it most. This important service helps seniors receive a quick and accurate diagnosis with follow-up support.
Senior Assessment Clinic appointments from April 2023 to March 2024
PCRNs may work with clinics that are dedicated to maternity care. PCRNs work alongside the referring doctor to support pregnant patients from the beginning of their pregnancy all the way to birth and beyond.
This care includes providing education and support for pregnancy and pain management, lactation, post-partum concerns, and more. PCRNs will work with each patient to answer questions, make targeted recommendations, and provide care for the patient and their child after birth.
Maternity appointments from April 2023 to March 2024
Program attributes
Virtual model
To enhance accessibility for our patients, our PCRN team shifted to a primarily virtual appointment model in 2020. Prior to this change, patients would need to visit their primary care provider’s office to see their nurse. Now, patients can visit their nurse through a simple video or phone call.
Our virtual care model reduces wait times for patients and ensures they can access the services they need from the comfort of their own homes. If preferred, patients have the option of in-person appointments at their doctor’s office.
The implementation of our virtual care model allowed for approximately 1,140 additional PCRN appointments per year.
Continuity of care
Collaboration and communication are essential components of the relationship between the doctors in our membership and nurses. To ensure continuity of care, nurses stay connected with our members to provide updates on patients and establish a strong working relationship.
This communication is often done through charting notes where PCRNs will keep a record of any relevant patient updates for the physician’s later review. Senior Services RNs will fax the referring doctor a summary of their consultation along with any recommendations that came from their patient visit.
Team accomplishments
Our virtual care model allows patients to connect with their PCRN through video or phone appointments with ease at a time that works for their schedule and a location that is comfortable for them. Patients are also able to request in-person appointments, if preferred.
Every month, a different member of the nursing team presents a health topic or chronic disease that may impact their patients — expanding their collective knowledge.
Significant updates have been made to PCRN charting forms and Senior Services RN templates; this ensures effective communication between our nurses and doctors.
In 2023, our PCRNs began assisting with referrals to the limited-time Alberta Lung Cancer Screening Program. So far, eight referred patients were found to have early signs of lung cancer.
Patient experience
Each year, our PCN conducts a Patient Experience Survey to determine how our community members feel about their experiences with our clinical team members. The results of our 2023 Patient Experience Survey were overwhelmingly positive. This feedback is reflective of the hard work of our nurses, their commitment to patient-centred care, and the effectiveness of our virtual care model.
of surveyed patients rated the care they received from a PCRN as excellent or very good.
of surveyed patients rated the care they received from a Senior Services Registered Nurse as excellent or very good.