How One Calgary Clinic Gets Team-Based Care Right
This season, we’re diving into innovative primary care practices across Canada—starting in Alberta, where one family practice is making timely, high-quality care a reality for more than 25,000 patients within a fully capitated model. In this episode, Tara visits Crowfoot Family Practice in Calgary—a clinic that’s getting team-based care right. Physicians here manage patient panels about 30 percent larger than their peers, thanks to a model where 35–40 percent of care is delivered by non-physicians. Executive Director Shauna Thome gives us a tour of the clinic, and then she and medical director Dr. Janet Reynolds join Tara in conversation. They talk about how the role of the physician on the team is different, how the team is piloting new ways to attach patients without a family doctor, and how continuous quality improvement—with patients as partners—shapes the clinic’s culture.
Research mentioned in this episode
Explore more about the Crowfoot Village Family PracticeTake a look at the case study evaluation Health Quality Alberta published on Crowfoot Read more about the Calgary Foothills Primary Care Network Dr. Janey Reynolds leads.
Read the final report from the Modernizing Alberta’s Primary Care System (MAPS) processCheck out this article that talks about how teams are our hope for the future and can theoretically help doctors care for more patients. See some photos of Crowfoot Village Family Practice
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How One Calgary Clinic Gets Team-Based Care Right
Primary Focus Podcast
Virtual Tour: Opening
Shauna Tommy (00:03) Hello there. I'm Shauna Tommy and I'm the Executive Director of Crowfoot Village Family Practice. I'm here at the clinic on a beautiful sunny day in Calgary to show you around.
Dr. Tara Kiran This is Shauna. She's showing us around the clinic she runs in Alberta. It's a clean and modern space that looks more like an architect's office than a clinic — with soft lighting, modern chairs with shiny steel-tubed legs, and a big curved front desk lit blue from below.
Shauna Tommy Our reception is so fresh and clean and welcoming. It's common-modern with comfortable chairs, and I love the big sign that greets patients as they walk in. Even better, I'm greeted every morning by our two lovely receptionists, Shiny and Alora. Now, they call themselves CVFP for short.
Dr. Tara Kiran In October 2024, I flew out to Calgary to give a talk at their primary care day. And when I did, I asked around: was there an innovative clinic in the area I could visit? A few different people pointed me to Crowfoot.
Now, I did bring an audio recorder with me to the visit — but let's just say I wasn't the seasoned podcast host I am today, and the recordings just didn't work out. So, lucky for me, Shauna agreed to give us a tour virtually.
Shauna Tommy So when patients arrive, our lovely receptionists direct them to an exam room on their colour team. Rounding the corner, I start at our Blue Team — and the Blue Team has a motto, which is "Nothing but blue skies."
Dr. Tara Kiran Crowfoot was founded in the early 1980s and currently serves more than 25,000 patients. It's home to 17 family doctors who together work the equivalent of about ten full-time doctors. It also has about 85 staff that the clinic hires directly — including nurses, physician assistants, a nurse practitioner, and medical office assistants, who we'll hear more about. There are also another ten staff provided through the primary care network.
They're also a training site: they support 16 family medicine residents, 15 physician assistant students, as well as medical students and other learners.
Now, it's important to mention that Crowfoot is a unique model within Alberta. Since 1999, it's operated as a fully capitated model — one of the only clinics in the province to do so.
Introduction
Dr. Tara Kiran (02:24) One of the reasons I wanted to feature Crowfoot on Primary Focus is because of their approach to team-based care. We've been talking a lot about a future that's different from the current state — one where everybody has access to primary care. And for that future to become a reality, we actually need family doctors to be able to care for more patients. One of the ways to do that is by having teams that can extend the expertise and experience of family doctors to larger populations. And here at Crowfoot, they've figured out how to make that happen.
Shauna Tommy Next, we reach a very unique role here at CVFP, which is our triage RN. This nurse works across teams, handling things like suture removal, B12 injections, urinary tract infections, respiratory infections, and other common conditions. It's a very important role — it expands access to care for patients and helps us run smoothly.
Dr. Tara Kiran They split their doctors and other health professional staff into mini-teams named by colours. These mini-teams are built around a few family doctors and a registered nurse. Each team also has several medical office assistants who answer phones and prep patients. And one of these medical office assistants actually serves as a team captain. There's a leadership development program for all team captains — and leadership development is taken seriously at Crowfoot. In fact, all staff have access to a learning and education fund. It's part of how they optimize team-based care.
Shauna Tommy Each team has a shared workspace where our registered nurses and medical office assistants sit side by side, and that helps them coordinate care and keep communication flowing. The energy is always lively, and you'll probably hear laughter mixed in with the serious work of care that happens here every single day. So next up is our Yellow Team. Every team functions much the same, but they each have their own flair. Yellow Team is always looking for ways to be more efficient and creative — they're like our innovators.
Dr. Tara Kiran Efficient and creative. It's actually a great way to describe the approach at Crowfoot. And that's why we're on this tour — to see how this clinic is listening to patients, using data, and constantly innovating to meet community needs.
Welcome to Primary Focus
Dr. Tara Kiran (04:56) Welcome to Primary Focus. I'm Dr. Tara Kiran. This podcast is meant to launch a conversation we really need to have about the current primary care crisis in Canada and how we're going to solve it.
For the past couple of years, I've been traveling around the world to see how primary care practices in other countries are managing to offer reliable, timely care to their patients. Last season, I brought you with me to the Netherlands in a four-part series where we broke down exactly what makes their primary care system one of the best in the world. This season, we're launching into a tour of innovative practices in Canada. And today, we're walking through a unique example of team-based care in Alberta that I think has a full rainbow of lessons to teach other Canadian clinics.
After this quick walkthrough of Crowfoot Village Family Practice and the context you need to know about primary care in Alberta, I'll be sitting down with Shauna and Medical Director Dr. Janet Reynolds to learn how they've built the practice to meet community needs.
Primary Care in Alberta: Context
Dr. Tara Kiran (06:03) Before we get back to Shauna's tour of the rainbow of teams that work so efficiently for Crowfoot, I want to give you some context about primary care in Alberta.
Most family doctors in Alberta are part of a primary care network. These networks were introduced in 2005 to try to improve access to primary care. The networks receive a fee for every patient of every doctor who's part of the network, and in turn use that money to support physicians and patients. Many use the funds to hire other health professionals — like nurses, pharmacists, dietitians, and behavioural health consultants — who work in different family doctors' offices through the week.
The networks develop grassroots programs to support the needs of the patients they serve, and to support team-based care. While the creation of these networks has been positive for physicians and patients in many areas, it hasn't solved all of the access challenges — because not enough patients have actually been able to benefit from those other health professionals. There's not quite enough to go around as it stands.
Dr. Tara Kiran (07:11) From folks I talked to in Alberta, it does seem that the networks have provided a really important infrastructure for primary care. At the same time, there's a lot of heterogeneity in how these networks operate across the province.
Dr. Tara Kiran (07:30) There's another piece of context I want to bring in about Alberta. A few years ago, the government launched a process called Modernizing Alberta's Primary Health Care System, or MAPS. The goal was to refocus primary care as the foundation of the health system, with input from lots of different stakeholders along the way. The MAPS process included a separate Indigenous panel as well as a strategic advisory panel — which was actually co-chaired by Crowfoot physician Dr. Janet Reynolds, who you'll hear from soon.
The MAPS strategic advisory panel published its final report in 2023. It included eleven recommendations covering how primary care is organized, how doctors are paid, and ways to strengthen team-based care — all with the goal of ensuring every person in Alberta has access to primary care. For example, it recommended new regional primary health care networks that are supposed to provide services to everyone in the region, not just people who are lucky enough to have a family doctor.
Dr. Tara Kiran Up until recently, most family doctors in Alberta were paid fee-for-service. But as of April 2025, family doctors are being paid in a new way. There's still some fee-for-service payment, but less than before. Instead, there's now an hourly payment for both patient visits and behind-the-scenes work, with a higher rate for after-hours care; a set payment per year for attached patients, adjusted for complexity; and a 10% payment for administration — which Shauna says they see as an acknowledgement that running a family practice takes a lot more energy, effort, and time from physicians and their staff.
This new payment model is meant to fairly compensate family doctors for the work they do, including work that happens outside of a patient visit. The hope is that it will attract more doctors to community-based family practice. If you want to know more, I chatted about these types of physician payment changes happening across Canada with Dr. Ruth Lavergne in our last episode.
So far, Shauna says there's been high uptake from family doctors in Alberta on this new model, but many are still what she calls "skeptically optimistic."
Dr. Tara Kiran (09:45) But as I said, Crowfoot is unique. These funding changes don't affect the clinic, because it's been operating on a fully capitated model since 1999. That means the clinic — not individual doctors — receives a set amount of funding per patient per year. And when one of their patients seeks care outside of their office — say, at an urgent care centre, a walk-in clinic, or an emergency department — there are financial penalties for the clinic. So Crowfoot needs to take extra care to ensure that patients can access care when they need to.
Tour Continued: The Teams
Dr. Tara Kiran Now let's get back to our tour. As Shauna says, each patient at Crowfoot is assigned to one mini-team. That team is responsible for offering primary care when and how the patient needs it. For example, if patients have an urgent issue, they call their mini-team to get a same-day appointment.
Shauna Tommy Next up is our Green Team. Now, CVFP is a teaching clinic, and while education happens everywhere here, Green is where you'll find the most learners. Each year we welcome up to fifteen family medicine residents and another ten to fifteen physician assistants.
Dr. Tara Kiran Where Crowfoot stands out is how they optimize their systems. Every member of their team — whether a doctor, a nurse, or a member of their office staff — is supported to work at the top of their scope.
Shauna Tommy Next, we have our Gold and Silver Teams. These were created back in 2010 when we expanded and took on 10,000 new patients. That expansion was huge for us — we recruited six new physicians, twenty staff, and it was a brand new chapter in our history.
Today, in 2025, we've grown to about 140 staff and providers, delivering care to more than 25,000 patients across Calgary and the surrounding area.
Dr. Tara Kiran Crowfoot's doctors focus on more complex care and consultation, while other team members handle more straightforward issues. In fact, between 35 and 40% of care at Crowfoot is delivered by non-physicians. Registered nurses are a big part of that — they triage patients, provide preventive care, and manage uncomplicated conditions like bladder infections and sore throats. And Crowfoot's health management nurses take on chronic disease management for patients with hypertension and diabetes.
These team members are funded through two different streams. Pharmacists and health management nurses are provided through the primary care network. But the registered nurses and medical office assistants are paid for through the capitation payments that come to the clinic. The cost of these team members has to be offset by the efficiency gains of doctors being able to care for more patients.
Physician panel sizes — meaning the number of patients formally registered with a doctor — are about 30% larger at Crowfoot compared to other physician practices in northwest Calgary. Shauna says historically they've aimed for a physician to have a panel of between 250 and 300 patients per half-day worked. Dr. Janet Reynolds works two and a half days per week and has a panel of 1,800 patients, so she's considered overpanelled — but she has a practice partner who is intentionally given fewer patients, so that together they have a balanced workload. They share about 3,000 patients and work a combined five and a half days per week.
Now, the clinic is fully capitated, with payments for each patient going to the clinic as a whole — but the clinic pays Crowfoot doctors mostly via an hourly rate for time spent on clinical work, as well as for time spent attending meetings, doing paperwork, and teaching. Doctors also receive some pay based on the size of their panel.
Shauna Tommy Finally, our newest addition is the Rainbow Team. We call it Rainbow because it draws from the brilliance of all of the colour teams at Crowfoot. The Rainbow Team is built around collaboration. It has four registered nurses, a full-time physician assistant, a group of navigators who are medical office assistants, working closely with a family physician — and it's a model designed to expand efficiency and rethink the physician role into more of a mentor and a guide. Supporting true team-based care. In the past year, the Rainbow Team has taken on 1,600 patients, and many of those folks from our community did not have a family doctor previously. We're learning so much about how this model works.
Patient Voice: Linda Anderson
Dr. Tara Kiran (14:28) So the tour doesn't quite stop there. At Crowfoot, they really understand the importance of patient engagement. Patients don't just receive care — they help shape it. They have a Patient Advisory Committee which provides patient perspectives on developing and rolling out new initiatives, like the Rainbow Team. Linda Anderson is one member of the Patient Advisory Committee.
Linda Anderson My name is Linda Anderson and I live here in Calgary. I worked for many, many years with Alberta Health Services in pediatrics, primarily with mental health and child abuse. I retired about four years ago, and unfortunately went right from retirement into illness — I was diagnosed with cancer. Very fortunately as well, I have been very well treated; the surgery and the treatment went very well. And at that time I was also in the process of trying to find a new physician. I was told about Crowfoot Family Practice, that it was a very good practice, and I put myself on a wait list. That's how I got in touch with them — and was contacted and asked if I wanted to sit on their steering committee to develop the Rainbow project.
Dr. Tara Kiran Linda says that as a member of the steering committee, her personal aim is always to provide the perspective of both a patient at Crowfoot — which she is — and someone who's worked in healthcare.
Linda Anderson I think when you're in whatever your business is at the time, you lose sight sometimes of the fact that there still are people there that are scared, are feeling very disconnected, not feeling supported. And when those voices are heard, I think people can feel: yeah, you know what, we're all going to benefit from this. And they are hearing me and what my needs are. So it's not just about the bigger system — about how can we do this for less money, how can we do this quicker — it's still about how can we meet the needs of those people that we serve.
And I'm so impressed with the family perspective they have here. They treat the individual, but they also appreciate the bigger family system. When we met as a patient group, I heard that over and over again from other people. "I'm by myself up here — the rest of my family is not connected to the clinic." And I heard through other people that their physicians have cared for their grandparents and their children and that whole family system.
Dr. Tara Kiran (16:52) Linda says having a clinic like Crowfoot listen to their patients and then actually use their insights to drive change is special. For example, when they launched the Rainbow Team, a working group of patients acted as the guinea pigs for the pilot — and their ongoing advice and feedback based on real-time experiences allowed the clinic to iterate and make changes to the process as they built it out.
And with her patient hat on, Linda says she feels really lucky to be attached to such a meaningful practice.
Linda Anderson I just feel like I've landed in a warm space. As I was leaving the acute care system and things were getting better for me, I did have a fear that accessing service was going to mean I had to go to emergency care. And I don't feel like that. I feel like if things come up, I have a place that can address those issues. And I know that I've heard other patients say that as well.
Dr. Tara Kiran And she says if she had one piece of advice to other practices wondering whether to take on a team-based approach like Crowfoot:
Linda Anderson Do it. It is so beneficial. And I think even other disciplines — what they can contribute, what they can add, not only for the patient, but for the entire team. There's a lot of value in a multidisciplinary approach. I think that's the way to go.
Cost-Effectiveness Data
Dr. Tara Kiran (18:14) Crowfoot is obviously a special place. And that's backed up by the numbers. An evaluation done by Health Quality Alberta found that Crowfoot provides more cost-effective care than other practices in the same community, especially when downstream health system costs — like emergency use and hospital stays — are taken into account. They estimated that in 2016, Crowfoot generated health system cost savings of about $4.3 million, and that the trend of health system cost savings was consistent since about 2007 — translating to an estimated ten-year accumulated savings of about $57.3 million.
Those are incredible numbers to consider.
Conversation with Shauna Tommy and Dr. Janet Reynolds
Dr. Tara Kiran To learn more about how they do things, I sat down with Shauna and Janet over Zoom. Before we jump in, here are their formal introductions.
Dr. Janet Reynolds Okay, well, thank you. I'm Janet, and I am a family physician here at Crowfoot Village Family Practice, where I work part-time on one of our teams, and I function as the Medical Director for the clinic alongside Shauna. I also have another leadership role in the system as Medical Director of what is right now the Calgary Foothills Primary Care Network, which is the network in northwest Calgary. We're the only PCN that has a rural component alongside an urban one. We have over a hundred family physician and nurse practitioner member clinics, and we support them with centralized and co-located health team members — pharmacists, health management nurses, team members who go into these primary care practices and support patient care. And centrally, we have social work and registered dietitians and health team support available for all patients, whether or not they have a family physician.
Dr. Tara Kiran You're also the co-chair of the MAPS process.
Shauna Tommy Yeah, Janet wears a primary care network hat, a Crowfoot hat, and a provincial hat. The lenses are many and broad.
And this is Shauna Tommy, who you've already met. I have the great privilege of working in a dyad with Janet — and Janet and I have known each other for fifteen years. I am the Executive Director of Crowfoot Village Family Practice. I joined the clinic fifteen years ago, almost reluctantly. I used to work in the acute care system here in Alberta, and I expected my career path to really expand there. But I took a meeting with Crowfoot to learn about the Executive Director role — and again, I was very reluctant. But I left that first meeting feeling like this was in complete alignment with the leader I wanted to be and the system change I really saw for Albertans, for myself, for my own family. And I never looked back.
So Janet is sort of the clinical brain — I'm the business brain. My background is entirely in business. And together we always say we basically make one whole brain.
Physicians Working at Top of Scope
Dr. Tara Kiran (21:50) Janet, one thing you've mentioned to me before is that in this team-based model, working to the top of scope isn't just about nurses, pharmacists, or social workers — it's also about physicians working to the top of their scope. And that can be a mindset shift. Can you speak to that?
Dr. Janet Reynolds Yeah, physicians are human — no surprise there. And so sometimes we crave something that's easy and uncomplicated because of the cognitive burden. Often what looks easy when you see it on your day sheet turns out to be a multiple-concern visit or way more complicated than you thought. And so we need that break. But I think if we design our work to give those breaks to physicians, our physicians all know that they're not going to be seeing one person for a wart or something really straightforward. They're supported by each other and the rest of the team around knowledge gaps as well, because we are seeing the most complicated patients.
And nothing is so black and white that I'm suggesting every patient needs an hour of my time because they're so complicated — we are booking fifteen-minute and thirty-minute appointments. But I don't come to work wishing I could have a straightforward viral upper respiratory tract infection. That doesn't work well for our system, because that means someone who needs me more can't see me. So it's really about maintaining access.
Dr. Tara Kiran I'm going to go back to the point you made that it's hard to keep seeing hard things. If your whole day is hard things, that can't feel good. So how is it that your doctors have been motivated to have a practice style and a team-based approach where most of the time they're seeing the more complicated cases?
Shauna Tommy I don't know if it's as simple as this — Janet, jump in — but I think part of this team-based model is that it's really important that we know who we are, that we know what we're doing and what our place is in the health system that Crowfoot has established. It might sound very business-y, but vision, mission, values, and the way we work together really matter. When we recruit people, we're looking for like-minded people who find this work extremely rewarding — who know that yes, they're going to see tough patients, but they have immense trust that they're supported by a team, that they're never delivering care alone, that they always have the opportunity to collaborate and to delegate.
Dr. Tara Kiran (24:16) I think the people we have on our team — just having a team behind you and knowing you have that support — really helps reduce that cognitive burden. That's not to say folks don't have hard days or hard cases. I think that's quite frankly present all through primary care. But there's something psychological, a safety in knowing we're in this together. And we very much value: when you're not here, you're not here. That is a break.
Dr. Janet Reynolds So I have Dr. Benedictson who does my inbox when I'm not here. When people take vacation, their patients get seamless care — you don't come back to anything. We really do value and promote breaks, and that's very much supported. And I would say it's not off the corner of our desk that we create our culture — we have regularly scheduled meetings, we do retreats. There's that little bit extra that makes people feel like we're all rowing the boat in the same direction.
Dr. Tara Kiran So much of what you're saying makes sense. Of course, we need to create culture and environment where people understand who they are and their unique contributions relative to the broader team and what's needed in the community. At the same time, I hear you saying you're recruiting for a certain kind of person. But if we want all family doctors to work this way, it's going to be a mindset shift for everyone. We don't have the luxury of saying you can work this way and you can work a different way. As a profession, that's something we need to challenge ourselves to think through.
The Rainbow Team: Innovation in Access
Dr. Tara Kiran (26:35) But I wanted to shift now to something I remember from when we met before — the challenge of people not having access to care. There are many people within your network who don't have any access to primary care. And I think your clinic feels an obligation to try and support as many of those people as you can. Tell me about the Rainbow Team and how that came to be.
Shauna Tommy When you were here in October, we definitely had a wait list of 4,000 families, and we were working to create capacity to attach unattached patients into our model. I would say that some of the system changes we're seeing — including a new funding model that offers physicians more stability — we're starting to see a shift in that. I don't know the exact number, Janet, but I think it's about 660 physicians in our area of the city who have opened practices in the last six months and are taking new patients.
Dr. Tara Kiran Wow. That's hopeful.
Shauna Tommy Again, that's our pocket — I'm not saying that's happening across Alberta by any means. But it is happening where we are. So what started as an opportunity to create capacity for our community is shifting.
What we developed — and I'll start there and then talk about how it's shifting — was a team that was perhaps less reliant on the physician. In our original teams, the physician is still essentially the first point of contact and the person who makes the decision about how the patient accesses care and who they access. And so it felt like a bit of a bottleneck and a potential delay for patients, and it was heavily reliant on the physician.
So we've redesigned care so that instead of the physician being that first point of contact, they're actually acting more as a consultant and a support to a broader team. The sixth team we have at Crowfoot is designed a bit differently. It has two full-time registered nurses with advanced scope of practice, a full-time physician assistant, and then a physician working at about 0.2 to 0.3 FTE — significantly less — to support a team that will ultimately be about 3,000 patients. The physician assistant and the nurses work together to do patient intakes, assess needs, and get patients attached to the right provider on that team. They do this in consultation with the physician, so patient care is always safe and attached to the right person — but it broadens our options in terms of attaching patients.
Dr. Tara Kiran (28:57) And it also allows you to employ more people in your community and not be as reliant on the position of a physician.
Shauna Tommy And as well, it's rewarding for a physician, because now they get to work with a broader team doing different kinds of work — still seeing the most sick patient, but spending a lot more time coordinating with the team, mentoring, supporting, coaching.
This is still in its early days — we've been doing this for just over a year and a half and we're still learning. And the system around us is evolving. Now what we're really looking at is a model of care that is sustainable from a cost perspective. We really want to make sure we're using those precious public dollars as best as possible. And so we're interested to see if this model — which focuses on the lowest cost provider working to the highest scope of practice, in collaboration with a physician — also lends some sustainability and viability.
Dr. Tara Kiran I mean, what I love there is that your ambition is to have 3,000 people being looked after by a physician who's actually only working there two to three half-days a week but is acting as a consultant. A family doctor is kind of the consultant to this team that day-to-day is looking after the needs of those 3,000 patients. That's quite ambitious. How has it been going so far, and what's the reception from patients?
Shauna Tommy This team couldn't function on its own without the larger team supporting it. Because patients might get sick and need to be seen just like any other CVFP patient — they would have access to the rest of the team as well. So it isn't just an isolated pocket, and that's really important. There's definitely a minimum cohort of people needed to share the workload. That's important to note — because if a patient on that team needed to be seen and there was no Rainbow physician that day, they could see any one of the other eight physicians who have access to appointments.
Dr. Tara Kiran (31:20) So the consulting physician is responsible for those chronic, ongoing needs — but you have cross-coverage within your broader team that everyone is a beneficiary of. So all of your 25,000 patients can always be seen by somebody else on the team if their most responsible physician isn't there.
Shauna Tommy And you're right, it is very ambitious. We're still learning.
One of the things we're paying attention to is the patient intake process. Some of these patients have not been attached to a provider. What was very interesting about this process is that we actually surveyed patients on our wait list while we were designing the team, to see if we could understand their perception of their own health needs — and whether that could help inform the composition of our team.
What we got back from patients who responded was: "I'm well and healthy. I simply want to be attached to a family physician." But as we took patients on from the wait list — we've taken on just over a thousand so far — that actually wasn't the case. We revealed a lot of maybe asymptomatic chronic disease. There's been a lot going on. Taking patients who are in the community and haven't been receiving consistent care is different than managing a panel of patients who are well-managed. It takes more work when you're taking on people who haven't had care for a long time.
Dr. Tara Kiran And I think what I'm also hearing is that some people who were out there in the community and thought they were well actually weren't as well as they thought — and would benefit from some chronic condition and preventive care.
Shauna Tommy That's right. So we don't exactly know yet what the composition of the team will look like once we're through that intake. We're very fortunate at Crowfoot that we have a Director of Quality Improvement, Dr. Karen Siegel — a family physician who is retired from practice, but also an epidemiologist. So in any of our quality improvement initiatives — and we would consider our Rainbow Team a quality improvement initiative right now — she's working with us to look at all the data, including experiential data from patients and from staff and physicians.
Dr. Tara Kiran (33:46) Tell me about that experiential data. Tell me about how patients are finding it.
Dr. Janet Reynolds First of all, we had patients involved in the design of the team. We did focus groups before we even started, to test these theories. And we had people who came into the focus group very skeptical who left saying, "Why isn't everybody doing this?" And I think we all know that personality match matters — we can't be everything to everybody — but it's been overwhelmingly positive. People feel grateful to be attached. They're very open to not only seeing a physician — once they understand scope and the concept of sharing the "halo" — we're moving people away from the very traditional "I need to talk to a doctor for everything."
We have lots of patient quotes. We have provider satisfaction that's off the charts, I would say. We go through our health team effectiveness survey to work on any areas of improvement.
Shauna Tommy And Janet, just to interrupt — are you talking about the Rainbow Team or about everyone together?
Dr. Janet Reynolds We measure it with every team, but I'm speaking specifically to Rainbow because it's different. The patients are much more engaged in their care right from the beginning.
One of the most important things to note is that this is different. When you think about the mental models that any of us — as patients — have been socially trained to expect from primary care, most people think: "I need a family doctor." Anything else is quite strange, because nobody taught us how the health system works or how to navigate it.
And so we have a lot of intentionality about this. We bring patients with us. We have a formal orientation program where patients join us over Zoom and we present the concept, talk to them about how it's different, and then have an open Q&A. We host those in forums of about fifty patients — voluntary, of course. And we've also taped a video for existing Crowfoot patients to talk to them about how we see care changing in the clinic.
Shauna Tommy (36:05) Interestingly, the Rainbow Team is comprised largely of patients from our community who are unattached — but they've also helped take on some patients from within Crowfoot. We had a physician retirement last year where we had some difficulty recruiting a direct replacement, and so we're moving patients over to this new service.
It's interesting that the patients who come from the community are so thankful to get care and very open to this. The patients who've experienced the traditional care model at Crowfoot are having, in some cases, a bit of a tougher time adapting. So our team is trained on how to walk alongside them through that, and sort of allow them to experience it and build a little bit of trust that it might be different, but they're still going to be very well cared for.
Patient Engagement: The PEP Squad
Dr. Tara Kiran There was so much to love about what you just shared — all of the measurement, all the work you did before launching this new initiative, and then all the ongoing measurement to understand whether it's working the way you wanted it to. Through all of that, it sounds like patients were at the forefront of helping you design it and helping you understand if it's working.
One of the things I love about the work you do is that you do it in partnership with patients. And I understand you have what you call a PEP Squad. Could you tell us a little about that?
Shauna Tommy (38:20) A couple of years ago, our board — the owners of our clinic — sort of thought: we talk the talk, but we aren't really walking the walk around patient engagement. We're very patient-centred in the care we deliver in the moment, but do we have patients involved in the design? So we put out a call to our patients to be Patient Engagement Partners — or PEPs — and be on the PEP Squad.
We really thought we'd be lucky if we had about twenty people respond. I think we had over 130 on the first call. And now we're up to close to two to three hundred patients. So anytime we're thinking about an initiative, we may send out an email blast asking for participants, or we may pick a demographic of patients that we want some feedback from and do a project with them involved.
The first project was our patient guide. It started out as a new patient guide, but we realized it's for all patients — not just new patients — and they helped with the design of the information: what patients need and want to hear from us, not what we want to tell them. So it's not the "Crowfoot rules of how you get care" — it's what patients might need to know around how to access care. That was our first project.
The most recent project is our newly launched internal patient feedback program. We recognized that it doesn't always feel safe for patients to deliver feedback on their experience, especially when it's constructive feedback or when care didn't meet their expectations. So we developed a very simple program — a secure web tool with three very basic questions about your care experience today. There's a QR code in every exam room, in our waiting room, and on our website. Patients are able to send in notes about their experience or questions.
For the most part, what we get is lovely feedback about some of the things they're experiencing. But we've also had constructive feedback that shows us where some of our gaps are in bringing patients with us in their care journeys. And that's allowed us to meaningfully engage with individual patients to learn more about their experience and where we might be missing something. We've just launched that — about three months of experience with it so far. Still more to learn. But it was completely co-designed with our PEP Squad.
Dr. Tara Kiran (40:39) This has been a big learning for me too. I really started getting more deeply into engaging with patients in my own work — both in a clinical setting to improve care, and in research — probably back in 2015 or 2016. And I remember people also feeling very worried that if they worked with patients, what they would hear would be a lot of criticisms or unrealistic demands they wouldn't know what to do with. And I found that when we were actually working with patients, people were very reasonable, very thoughtful, and also extremely grateful to be cared for. They wanted to contribute in a really positive way.
And to your point, Janet, what I always love is that they challenge my own thinking — there have been many times I've walked into an engagement predicting what I might hear, and then heard something very different than what I expected. There's no way I could have predicted it; I couldn't have done it without them.
Dr. Janet Reynolds It's really interesting to navigate the health system as a quote-unquote expert, experiencing it from the side of delivery. And then it's such a privilege to talk to a patient who offers you their authentic experience in such a constructive way that you can co-design. I mean, I think when I reflect on our conversation today, I'm also reflecting on some of the priorities put forward by the MAPS process — including embracing patients and citizens as partners to empower people and communities around the primary care system, and accelerating efforts to ensure every person in Alberta can be connected to a patient medical home that provides team-based care.
You talked about how that wasn't really the case in Alberta twenty or even ten years ago, and now it's happening more and more. We talked about quality, governance, culture, organizational culture, payment. As we close out, I wonder if there's anything else you wanted to share about the clinic, the work you're doing, and how your clinic interfaces with the primary care network and the broader province — and what other networks or provinces might be able to glean from the work you do.
Sharing What Works
Shauna Tommy (43:04) I would say we are always open and early adopters of any service that might fit the needs of our patients.
Dr. Janet Reynolds The other thing Shauna hasn't talked much about yet is that we were a one-of-one in Alberta for a long time. You know, that was a blessing and a curse at the same time — because "you're Crowfoot, you're different" was sometimes used as a reason to stall progress elsewhere, because others felt like this wasn't accessible to them. They weren't Crowfoot.
So what I would say is: we have a lot of outward-facing advocacy. And I hope it's with humble authenticity, because we are equally open to learning from anyone else. When you came, you said you were blown away by the care we're providing. And we were equally blown away by the research work and the Our Care interviews that happened across the country and the structure and rigor of all of that.
But we do do a lot of that advocacy. We will sing from the rooftops about what we're doing if anyone would like to listen. That includes with bureaucracy and politicians — it's strategic and it's not a coincidence at all. You kind of make your own luck sometimes.
Shauna Tommy You read my mind. How I would describe it is: there are pockets of brilliance all over this province and all over this country. We're so fortunate to occupy this little corner of the world and have the funding that we do. And one of the things we're constantly talking about is scalability and spread. When we have this ability to learn — I call it a petri dish, but Janet calls it a test kitchen —
Dr. Janet Reynolds Yeah.
Shauna Tommy — we get to build really neat things with our team, and we have protected time to do that. So we engage with our community to share what we learn and talk to them about how things might be adapted. And we learn something from everybody that we engage with. We're a learning organization, and we recognize that even though we've been doing something for 25 years, there's still so much more to learn. We do protect time to engage with folks from all over Alberta and even Canada — to co-collaborate and do cross visits, cross-pollination of the brilliance that's happening everywhere.
Dr. Tara Kiran Well, I will say that based on what you've told me today, there's a lot we can learn. I'm situated in Ontario and we do have teams here, but I don't think we've universally been successful in structuring our teams in such a way that the whole is much greater than the individual parts. In particular, I don't think we've cracked that nut around how a team can really enhance physician and NP capacity to care for more patients — so that more people in Ontario, in Alberta, and across the country have care.
What you shared today were some wonderful pearls about the approach you've taken as a team — how you've built a positive environment, the day-to-day details of how different people make it work so that physicians can care for more people and more people can get care within a setting that can deliver the full scope of primary care, even if that doesn't mean seeing a physician every day. And what I really love too is just the patient and public partnerships you've taken on — to help continually design and improve the care you deliver, through patient feedback and through your attention to data.
Closing Reflections
Dr. Tara Kiran (47:35) I've been reflecting on this conversation, and I think there are a few things that clinics in Canada can take away from what Crowfoot does.
I think it starts with the deliberate development of shared mission, vision, and values that align the entire team around their joint purpose. They don't just take teamwork for granted — they are actively and continuously developing their team's leadership capacity to ensure people work well together. Roles are really defined and they're complementary, not duplicative. Everyone is working to the top of their scope, and that includes family doctors.
It's really interesting to me how family doctors on this team are often working as consultants — seeing some of the most complex, challenging cases — but in a way that's supported, so that when they're not in clinic they can really take a break, and when they are in clinic they know not everything is on them alone. They've got a whole team caring for the patients.
And of course, Crowfoot is not okay with just maintaining the status quo. They're always looking to change, innovate, and do better. They're collecting data, looking at data from their electronic medical records and from other sources, but also specifically getting feedback from patients to guide how they do things differently and how they can be better. That kind of dedication to continuous quality improvement is something that all teams would benefit from.
A huge thank you to Shauna and Janet for welcoming me to their clinic back in 2024 and for agreeing to be interviewed again for this podcast. A special thanks to Patient and Steering Committee member Linda Anderson for sharing her connection with Crowfoot Village Family Practice with us as well. I hope you found this conversation just as inspiring as I have.
If you want to know more, head to our show notes where we've included some photos of the Crowfoot clinic as well as some resource links.
Credits and Closing
Primary Focus was created by Dr. Tara Kiran and is made possible by a grant from the St. Michael's Foundation. Maryam Danesh is our research coordinator. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca. And if you'd like to read more content from Dr. Kiran about Canada's primary care system, follow her on LinkedIn.
We'd really appreciate it if you could send this episode along to a friend or colleague. Don't forget to give us a follow on your favourite podcast app. We'd also love to hear ideas from you or comments about what you think of these episodes — email us at primaryfocus@unityhealth.to.
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The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.