Introducing Group Health Centre’s (GHC) Primary Care Advanced Support Program, a reimagined and enhanced approach to delivering comprehensive, patient-centred care for individuals with complex health needs and chronic conditions.
This program is not new but a thoughtful rebranding of the Congestive Heart Failure and Family Health Worker Registered Nurse (RN) services. Building on the success of its previous services, this newly rebranded program focuses on supporting patients with multiple chronic conditions, especially those who may have difficulty leaving their homes or require more frequent monitoring. Through scheduled in-home visits or in-office appointments, skilled Primary Care RNs provide personalized care and help patients navigate the full range of GHC services.
At the heart of the program is a flexible, responsive model of care that includes heart failure services, individualized education, health monitoring, and comprehensive care coordination. Whether patients need a medication review, a follow-up after a hospital discharge, or a wellness check, the team meets them where they are, both physically and in their health journey.
“We go to the patients,” explained Jennifer, a Registered Nurse on the team. “Whether they need a medication review, a follow-up after a hospital stay, or even a wellness check, we’re there to provide them the support that they need.”
What sets the Primary Care Advanced Support Program apart is its ability to provide consistent, relationship-based care that adapts to each patient’s evolving needs.
“The great thing about our team is that we ensure continuous care,” said Tina, another RN in the program. “We reinforce health teachings, provide real-time support, and help patients adjust their care plans as their needs evolve.”
This ongoing support plays a key role in preventing unnecessary Emergency Department visits by identifying issues early and coordinating care with the patient’s primary care provider. In some cases, the team even accompanies patients to appointments, offering reassurance and continuity of care.
The program continues to make a meaningful difference in the lives of patients with complex health needs. By bringing compassionate, personalized care directly into the home, Primary Care RNs empower patients to manage their chronic conditions better, reduce hospital visits, and feel more supported and connected to their care team.
The Primary Care Advanced Support Program is available to GHC-rostered patients and Access Care Clinic registered patients who meet specific eligibility criteria.