Collaborative care

Collaborative care clinics are teams of health-care professionals who work together to support your health needs and offer more timely, accessible and coordinated care. Each team can look different. Depending on the team, you may have access to other health professionals (such as nurses, pharmacists, physiotherapists, respiratory therapists, social workers) in addition to your primary care provider. You may also be seen by another primary care provider on the team if your provider is away. With electronic medical records, team members will be able to make sure they offer you appropriate and coordinated care.

Improving access to primary care is a priority of the provincial health plan, and collaborative care supports this ongoing effort. New Brunswick is actively advancing this model. Through investments and partnerships, the province is helping regional health authorities and primary care providers establish teams across the communities.

The College of Family Physicians of Canada (CFPC) has endorsed the Patient Medical Home model of primary care, where physicians, nurse practitioners and allied health professionals work together to meet patient needs. It has been described as the place patients “feel most comfortable presenting and discussing their personal and family health and medical concerns” (College of Family Physicians of Canada).

Team-based primary health care should embody the following features:

• Patient-partnered care: You’re treated as a key member of your care team. You’re encouraged to ask questions, share concerns, and participate in decisions.
• First-contact access: For routine primary care needs, your health team should be your first point of contact — whether via in-person visits, virtual options, or phone consultations.
• Comprehensiveness, coordination and continuity: Care is organized across providers and over time. Your health information is shared (securely) among team members so that care is seamless.
• Accessibility: Providers should strive to respond to your primary care needs within five days, where clinically appropriate.
• Equity and locality: Care should be responsive to community needs, ensuring people in all regions receive comparable service levels.
• Technology and integration: Electronic health records, digital tools, and secure data sharing power more efficient and informed care.
• After-hours availability: As part of the team, health professionals provide access beyond regular office hours.
• Ongoing evaluation and accountability: Outcomes and performance are tracked, and teams adjust based on results and feedback.

The transformation toward collaborative-care teams is actively underway, with progress in multiple regions. Recent steps include teams established in: Campbellton, Moncton, Miramichi, Carleton North, Tantramar, Île-de-Lamèque, Edmundston and Fredericton.

Each team can look different, depending on community needs. Teams may include:

• Family physicians
• Nurse practitioners
• Registered nurses
• Licensed practical nurses
• Medical office staff
• Dietitians
• Mental health counsellors / therapists
• Occupational therapists
• Physiotherapists
• Pharmacists
• Social workers
• Psychologists
• Respiratory therapists
• Physician assistants

You are central to the success of collaborative-care teams. Here’s how you can actively engage:

• Reach out to your care team first for primary health needs
• Be open in sharing your health concerns
• Ask questions until you understand your diagnosis and treatment
• Keep an up-to-date list of your medications
• Request written instructions or summaries if that helps you
• Share any preferences or needs (e.g. language, accessibility, transport)

Your primary care provider may be either a family physician or nurse practitioner. In a collaborative-care system, your provider will:

• serve as your first point of contact
• work collaboratively as part of a team
• use electronic health records that are shared, securely, among team members
• strive to offer care within five days for non-urgent issues
• provide in-person or virtual care based on what’s clinically appropriate and preferred by you
• include allied health professionals (e.g. occupational therapists, pharmacists, social workers) when needed
• offer after-hours access with team support
• deliver care tailored to your community
• participate in continuous learning, evaluation, and improvement

Collaborative care is more than a new way of organizing providers — it is a response to the changing realities of health care in New Brunswick.

• Growing complexity of care needs: Many patients live with multiple conditions that benefit from coordinated care.
• Workforce pressures: To manage shortages and gaps, team models allow skills to be optimized across providers.
• Better access & equity: Team-based approaches help ensure that rural and small communities are not left behind.
• Innovation & technology: Digital health tools, shared records, and virtual care make team-based delivery more feasible and efficient.

By addressing today’s challenges and opportunities, this model ensures patients receive more coordinated, timely and equitable care.