Program overview :
Promising Practices for Strengthening Primary Care in Northern, Rural and Remote Communities
The Strengthening Primary Care program brought together 20 teams of primary care providers, organizations and communities from northern, rural and remote communities across Canada to improve access to primary care.
With support from the program, the teams introduced promising practices — approaches that improved access to safe, including culturally safe, team-based primary care — by meeting the unique needs of communities, patients and providers while encouraging collaboration and shared learning across Canada. One of the 20 teams (Newfoundland and Labrador Health Services) advanced five unique promising practices to respond to the needs of people and providers throughout their province.
Explore the short summaries of promising practices
Addressing family doctor shortages with virtual care (Petawawa Centennial Family Health Centre, ON)
The Integrated Virtual Care (IVC) program connects patients to their family doctor and primary care team in a region where 20% of residents lack access to primary care. The program has expanded to three primary care clinics, enrolled over 6,500 new patients, and reduced avoidable emergency department visits.
Optimizing team-based primary care (CISSS Montérégie Centre, QC)
The Advanced Access Quality Improvement Coach Model provides primary care practices with the tools and skills to better align patient needs with available resources. So far, 37 primary care clinics across Canada have adopted this model. In just six months, four clinics in Quebec have already reported promising results.
Expanding Access to Team-Based Care (NL Health Services, Conception Bay North, NL)
To address the shortage of team-based primary care, the Family Care Team Access model connects private clinic doctors with allied health professionals within family care teams. This innovative approach ensures seamless referrals and better coordination of care. In just three months, private family doctors are reporting an increased capacity to work at the top of the scope of practice.
Improving Primary Care Through Community Collaboration (Algonquin Family Health Team in collaboration with NOSM University, ON)
The Annex, a nurse practitioner-led clinic in Huntsville, increases access to team-based primary care in a region where over 4,000 residents are without a family doctor. Located in a community library, The Annex has reduced avoidable emergency visits, supported recovery for discharged patients, and earned praise from patients and providers alike.
Addressing After-Hours Primary Care Needs with Regional Nurse On-Call (Cree Board of Health and Social Services of James Bay, QC)
The Regional Nurse On-Call (RNOC) program is a centralized virtual triage service addressing after-hours primary care in Cree communities of Northern Quebec, where nursing shortages have created challenges. The program has triaged over 6,200 calls, resolving more than 50% of cases over the phone and reducing avoidable visits to local clinics.
Enhancing Health Centre Services in Nunavut (Government of Nunavut, NU)
Piloting extended hours in Rankin Inlet, Pond Inlet, and Kugaaruk, Nunavut’s Department of Health is bridging gaps in community care. Guided by Inuit Societal Values, this initiative aims to reduce after-hours registrations and improve both patient and staff experiences. Early feedback highlights its potential to improve access and reduce system strain.
Pathways from Emergency to Primary Care (Nova Scotia Health, Neil’s Harbour, NS)
To improve same-day and next-day access to primary care and reduce emergency department visits, Nova Scotia Health introduced a Registered Nurse (RN) prescriber to the primary care team in Neil’s Harbour. Since implementation, 23% of patients with less urgent needs have been redirected from the emergency department to primary care, with additional same-day appointments preventing unnecessary ER visits.
Point-of-Care Renal Screening (Prairie Mountain Health, MB)
To address barriers in early detection and treatment of kidney disease among Indigenous communities, Prairie Mountain Health launched a point-of-care renal screening initiative. This program provides culturally safe, team-based preventative care in four First Nations and one Métis community, improving access to early diagnosis and specialist referrals. Since launch, 142 individuals have been screened, with those at risk receiving timely interventions.
Type 2 Diabetes Remission Services (Rural Coordination Centre of BC, BC)
The Rural Coordination Centre of BC is working with the communities of Tumbler Ridge and Port Alberni to integrate food-based approaches into diabetes care. More than 200 healthcare providers have been trained to assist patients on their remission journey, and community pharmacies now offer point-of-care diabetes testing, improving accessibility.
More promising practices
- Better Health Innovation Access to Team-based Primary Care (PDF 100 KB) (ConnectWell Community Health)
- Canadian Health Advanced by Nutrition and Graded Exercise Program (PDF 141 KB) (Pacific Northwest Division of Family Practice)
- es zúmin’ Primary Care Centre (PDF 220 KB) (Líl̓wat Health & Healing)
- Expanded Primary Healthcare Team (PDF 254 KB) (Saskatchewan Health Authority)
- Global Spine Model of Care (PDF 322 KB) (Cross Lake Band Health Services)
- Improve Access and Receptiveness for Cancer Screening in First Nations Communities (PDF 124 KB) (Sunset Country Family Health Team)
- NL Health Services teams
- Mobile Primary Healthcare Teams (PDF 121 KB) (Central Zone)
- Primary Care Pop Up – Carbonear Impact Clinic (PDF 123 KB) (Eastern Zone 2)
- Mobile Care for Screening and Treatment (PDF 121 KB) (Labrador-Grenfell Zone)
- Patient Pathways to Family Care Team Services (233 KB) (Western Zone)
- Staying Healthy Clinic Improve Access for Older Adults with Chronic Conditions and/or Declining Health (PDF 572 KB) (Horizon Health Network)
- Virtual Care in Remote First Nations Clinics (PDF 102 KB) (Vancouver Island Health Authority)
- Virtual Care via Mobile Internet in Northern Communities (PDF 192 KB) (Northern Interior Rural Division of Family Practice)
