Mosaic of Care
Mosaic PCN Report to Community
Last updated March 2025
Data presented throughout this report is from FY 2023-24, unless otherwise indicated.
Data presented throughout this report is from FY 2023-24, unless otherwise indicated.
What is The Mosaic of Care?
This report, The Mosaic of Care, is a dynamic resource that embodies Mosaic Primary Care Network's (MPCN) commitment to transparency and adaptability as we address the community's evolving needs. It focuses on four key priorities:
Pathways to Patient Care
Improving access to care for vulnerable individuals and unattached patients without a regular primary care provider.
Supported Providers, Strengthened Care
Supporting primary care providers through resource sharing, quality improvement projects, and enhanced care delivery systems.
Partnerships for Patient Progress
Collaborations across the Calgary Zone, along with our own community and clinical partnerships, to amplify our impact and advance our progress.
Collaborative Care
Implementing team-based approaches that prioritize holistic wellness through multidisciplinary teams.
At the outset, you’ll find an introduction to our organization, an explanation of what we mean by "medical home," and insights into the patients we serve. To make our report as accessible as possible, we've also included a dedicated section, Prescription for Understanding, to clarify common terms and acronyms.
Mosaic Primary Care Network: Who we are
At the heart of northeast and southeast Calgary's healthcare community, Mosaic Primary Care Network (PCN) weaves together comprehensive medical care with deep community understanding.
Extensive Community Impact
Our network of 400+ family doctors and healthcare professionals serves over 465,000 residents, delivering innovative, culturally sensitive care at no cost.
Strategic Coverage
Our strategically located member clinics serve the urban area east of 14 St W, from the Bow River to the eastern city limits, and from the northern city limits to Anderson Road/114 Ave SE.
Collaborative Healthcare
As a non-profit organization, we create an integrated healthcare experience that combines medical expertise with local insights to meet our community's unique needs.
Where to find us.
Calgary Mosaic Primary Care Network (PCN) is consolidating all services at our new Sunridge Mall Clinic, providing streamlined care in an accessible location. This strategic move enhances collaboration and integrated patient care while maximizing resource efficiency. Learn more.
Better Access
Located on Calgary's C-Train line with free parking and transit options, making healthcare more accessible to our community.
Enhanced Collaboration
Uniting after-hours care, our ACCESS clinic, and multidisciplinary healthcare teams for seamless care coordination.
Community-Centered Design
Inspired by the Bow River, our new clinic serves as an inclusive gathering space reflecting our city's diversity.
Designed With Community Input
Developed through engagement with our staff, patient advisory group, and community partners to address everyone's needs.
Mosaic's Vision, Mission, and Values
In June 2024, we proudly launched Mosaic's refreshed Vision, Mission, and Values-cornerstones of our organization's future. Together, they provide clarity, cohesion, and a unified direction essential for navigating challenges and achieving sustainable success.
Our Vision
Achieving excellence in primary healthcare outcomes within our diverse neighbourhood.
Our vision serves as a beacon for where we aim to go, providing clear direction and guiding our strategic planning and decision-making.
Our Mission
Your partner in providing exemplary healthcare experiences within our evolving communities.
Our mission defines our core purpose, aligning daily operations with broader goals and ensuring consistency in delivering exceptional care.
Our Values
Embrace Diversity; Build Community; Lead with Compassion; Drive Innovation
Our values guide behaviours and set ethical standards, providing a moral compass for decision-making and fostering a sense of belonging among employees.
Through employee values integration sessions and ongoing sustainment activities, we're establishing a solid foundation for a cohesive, purpose-driven organization dedicated to enhancing our effectiveness and improving patient outcomes for everyone in our diverse and vibrant neighbourhood.
The Mosaic of our Community
Welcome to Your Medical Home
A Comfortable Space
Your medical home is where you feel most comfortable discussing personal and family health concerns.
Family-Centered Care
A trusted environment where your whole family can receive personalized healthcare attention.
Coordinated Care Network
Your family practice coordinates with other healthcare providers and community services in your medical neighbourhood.
By the numbers
90%
Patient Satisfaction Rating
Based on 2,244 total responses
4 days
Next Available Clinic Visit
Average wait time at member clinics
55K
MDT Patient Visits
Total one-on-one patient visits with MDT
20 days
MDT Appointment Wait
Time to next available MDT* appointment
*MDT: Multidisciplinary Team (for example, dietitians, footcare nurses, mental health therapists)
Pathways to Patient Care
"Our goal is to help improve patient outcomes and reduce the strain on the healthcare system."
- Abhinav Walia, Director of Access and Attachment
02:22
Mosaic Pathways Stepping Stones to Patient Care
Pathways to Patient Care
11.2K
Combined physician and nurse practitioner visits
22%
Of all provider visits conducted virtually
486
*Unattached patients supported by MPCN nurse navigators
In-Person Visits
Physician
4,464 visits
Nurse Practitioner
4,271 visits
Virtual Care
Physician
1,177 visits (21%)
Nurse Practitioner
1,288 visits (23%)
* "Unattached patient" refers to individuals who do not have a family doctor or nurse practitioner for routine, ongoing primary health care.
Supported Providers, Strengthened Care
Our Medical Home Support Program (MHSP) team collaborates with doctors and nurse practitioners to enhance quality of care through targeted improvement initiatives. We ensure each provider within the MPCN receives timely, customized support to achieve excellence in their unique Patient Medical Home (PMH) practice.
06:23
Empowering Essential Providers Day in the Life of a Health Promotion Facilitator
Supported Providers, Strengthened Care
A Patient Medical Home (PMH) is more than a clinic—it's a comprehensive care model where patients connect with the right support at the right time. At its core is a family care provider (doctor or nurse practitioner) supported by a multidisciplinary team, working in harmony to deliver patient-centered care throughout every life stage.
Language Access Support
Provides essential translation services with impressive growth in 2023-24: 4,353 patient visits and 464,133 minutes of usage, supporting nearly 90 different languages with top needs in Arabic, Dari, Tigrigna, Somali and Pashto.
Education & Updates
We provide access to continuing medical education and keep providers informed through a dedicated portal and regular, timely updates focused on the programs and services most needed by their patients.
Practice Facilitation
Our Medical Home Support Program team maintains regular communication with providers, gathering feedback and addressing concerns while supporting CII/CPAR transition and other operational improvements.
Quality Improvement
Through evidence-based practices and continuous evaluation, we support the optimization of clinic processes to enhance patient care and achieve better health outcomes.
Supported Providers, Strengthened Care
Patient Assistance
Through their primary care providers, patients gain direct access to our team of specialized healthcare professionals who provide personalized support through both individual and group sessions. Our comprehensive services include expert guidance in diabetes management, specialized foot care, innovative pain management solutions, mental health therapy, social work, and effective tobacco cessation programs.
Supported Providers, Strengthened Care
Celebrating our Primary Care Providers
At our Annual Meeting in June 2024, we were excited to present the following awards:
Oliver David Award
17th Avenue SE Medical Centre
Awarded to Dr. Oliver David and Dr. Perry Glimpel for excellence in implementing the Patient's Medical Home model. The 17th Ave centre distinguished itself through outstanding work in quality improvement, access, team-based care, and partnership.
This award recognizes clinics that demonstrate significant advancement of the Patient's Medical Home within their primary clinic, embodying the principles of patient-centered care.
Mark Sosnowski Award
Dr. Adam Neufeld
Dr. Adam Neufeld from Riverbend Medical has made significant contributions through their dedication to comprehensive care, addressing social determinants of health and patients' psychological needs.
This award honours primary care providers who embody patient-centered care principles and show extraordinary service to Mosaic's community through their innovative approach and compassionate care.
Partnerships for Patient Progress
Partnerships: Calgary Zone
There are seven PCNs in the Calgary area. They work alongside more than 1,700 family doctors in 450 clinics to provide care for 1.4 million patients. PCN teams include more than 400 nurses, mental health therapists and other health professionals. The seven Calgary-area PCNs form the Calgary Zone, which is the largest of five in Alberta.
Calgary Zone programs are available to all Primary Care Networks in the Calgary Zone.
3.3M
Alberta Find a Doctor Visits
With over 2.1 million unique users (since launch)
+41%
Increase in AFAD website visits in 2023-24
As more Albertans seek primary care
150
Mental Health Clinic
Referrals across Calgary's 7 PCNs
Key Programs
Connecting primary care providers and specialists since 2014 through tele-advice services and pathways. Top specialties include hematology (2,048 requests), obstetrics gynecology (1,686), and endochrinology (1,676).
Alberta Find a Doctor (AFAD)
A PCN-run provincial website launched in 2019 connecting Albertans with healthcare providers. Achieved record growth with 1.18M visits in 2023-24, a 41% increase in users, though seeing a 39% decrease in physicians accepting patients.
Access and Attachment
Successfully reduced patient wait list by 61% (from 8,272 to 3,229) through the Calgary Zone Coordinated Attachment Program.
Clinical & Community Partnerships
1
Community Outreach & Events
Connected with over 600 community members in our catchment area through events with local partners - sharing information about finding a primary care provider and PCN services.
2
Educational Workshops
Provided workshops for both staff and clients from partners on finding a doctor, benefits of having a patient medical home, and Mosaic programs and services.
3
Clinic Design Engagement
Engaged partners and clients for feedback on design and service delivery considerations for our new centralized clinic space at Sunridge Mall through interviews, focus groups, and surveys.
Community & Clinical Partnership Highlights
Social Work Partnerships
Partnerships with WINS, Basically Babies, Onward Homes, and Senior's Secret Service supporting patient access to essential resources.
Gateway Success
Partnership with Gateway resulted in over 900 newcomer referrals to Alberta Find a Doctor website.
Calgary Foodbank Initiative
Collaborated on dietician advice for food hampers, created healthy recipe videos, and organized employee volunteer programs.
Community Education
Ongoing mental health and wellness radio interviews on Red FM, plus educational support for University of Calgary students in healthcare programs.
Collaborative Care for Holistic Wellness
Integrated Healthcare Team
Our comprehensive care team includes primary care nurses, dietitians, pharmacists, social workers, mental health therapists, footcare nurses and kinesiologists working together to support your wellness journey.
Flexible Care Options
Access our services through medical home referrals, centralized MPCN clinics, or convenient phone and video consultations for personalized health support.
Personalized Support
From brief interventions to long-term case management, we tailor our approach to your unique health goals and challenges.
Visit Statistics - Mosaic PCN
Our healthcare teams conducted 27,117 patient visits across various disciplines in 2023-2024, with 63% of all consultations delivered virtually. Primary Care Nurses led with 12,225 total visits
63%
Virtual Visits
Average across all services
5.5
Daily Visits
Average visits per clinical day
27K
Total Visits
Annual patient consultations
Our Multidisciplinary Team Services
Mental Health Therapy
- Short-term counselling (up to 6, 1-hour sessions)
- Evidence-based treatments including CBT and solution focused therapy
- Support for depression, anxiety, grief, and loss
Social Work
- Resource navigation and benefits application assistance
- Support for life transitions and basic needs
- Community service referrals
Nursing Care
- Chronic disease management
- Certified Diabetes Education
- Health monitoring and education
Pharmacy Services
- Medication review and optimization
- Cost-effective medication planning
- Specialized respiratory and diabetes care
Dietitian Services
- Chronic disease nutrition management
- Culturally sensitive counselling
- Specialized dietary support
Kinesiology
- Certified Exercise Physiology services
- Customized physical activity planning
- Pain and mobility management
Pain Management
Specialized Care Team
Our multidisciplinary team includes physicians, nurse practitioners, and a team of allied health professionals who have provided over 4,000 patient visits last year, ensuring comprehensive pain management support.
Chronic Back Pain Management
The clinic specializes in treating chronic back pain that has persisted over three months, supporting patients living with pain utilizing a biopsychosocial-spiritual approach.
Fibromyalgia Support
Dedicated treatment programs for patients with Fibromyalgia or Fibromyalgia-like nociplastic pain, providing increased access while supporting MPCN physicians and community healthcare providers.
Mental Health and Social Work
Mental Health Support
Our mental health therapists provide 6-session support for depression, anxiety, PTSD, and other concerns. Services include one-to-one counselling and group classes, with flexible evening, video, and telephone appointments available.
Social Work Services
Social workers assist with life transitions, resource navigation, and improving social wellbeing. They help address financial pressures, disability support, medication affordability, and resettlement needs through both in-person and telephone appointments.
Telephone Triage Support
Our enhanced telephone triage system ensures timely support and resource coordination for urgent or complex cases, allowing us to efficiently address high-priority needs and provide rapid assistance.
Prescription to Understanding
A guide to Mosaic's terminology and acronyms
Job Titles
- CHN - Community Health Navigator
- CPS - Clinical Projects Specialist
- ED - Executive Director
- EMR Specialist - Electronic Medical Records Specialist
- HPF - Health Program Facilitator
- Kin - Kinesiologist
- LPN - Licensed Practical Nurse
- MHT - Mental Health Therapist
- MHSP - Medical Home Support Program (team)
- MPCN - Mosaic Primary Care Network
- MOA - Medical Office Assistant
- NP - Nurse Practitioner
- PA - Physician Assistant
- PCC - Primary Care Coordinator
- PCM - Primary Care Manager
- PF - Practice Facilitator
- RD - Registered Dietitian
- RN - Registered Nurse
- Rx - Pharmacist
- SPA - Special Projects Administrator
- SW - Social Worker
Programs and Services
- CDM - Chronic Disease Management
- CII/CPAR - Community Information Integration/Central Patient Attachment Registry
- EAP - Employee Assistance Program
- MHSP - Medical Home Support Program
- Mosaic Cx - Mosaic Connection
Other Important Terminology
- AIM - Access Improvement Measures
- CME - Continuing Medical Education
- EMR - Electronic Medical Record
- KPI - Key Performance Indicators
- MDT - Multidisciplinary Team
- PBH - Partners for Better Health
- PHC - Primary Health Care
- Unattached - individuals who do not have a family doctor or nurse practitioner for routine, ongoing primary health care.
