Integrated Care: It Takes a Team

The waiting room at Bonnie Doon Medical Clinic is standing room only this windy April morning. But the crowd gathered in this comfortable neighbourhood clinic isn’t here to renew prescriptions or have their blood pressure checked. They will be seeing the doctor, but in a totally new way.

They’re here for Walking on Wednesdays (WOW), an innovative program introduced by family practitioner Dr. Michael Hamilton, a member of the Edmonton Southside PCN. Since December, a dedicated group of patients meets weekly for an hour of fresh air and exercise – and are joined by Dr. Hamilton and other clinic staff, letting patients connect with their health providers in a different way.

“After 25 years in practice, I want to provide a practical way for patients to be more active,” Dr. Hamilton says. “We try to deal with all aspects of a person’s health here, and so wanted to try something new to educate and encourage people.”

Joining today’s group are clinic patient Manfred Kraft and Rhiannon Jacek, a PCN exercise specialist who works part-time at the clinic. “Rhiannon suggested I try it,” says Manfred of the walking group, “and I’m enjoying it.” He’s an active retiree and grandfather who often bikes and skis, but also contends with long-term chronic health concerns of colitis and diabetes.

Since his usual colitis medication stopped working a couple of years ago, Manfred has been working with Dr. Hamilton and the team at the clinic to find solutions. The Bonnie Doon Medical Clinic team organized a referral to a gastroenterologist and an MRI, and stayed connected when Manfred required a monthlong hospital stay. Whatever urgent care Manfred may require, he remains a long-term patient and priority of Dr. Hamilton and his staff.

Manfred’s team includes Rhonda Abbott, registered nurse and primary care team member, who is a part of today’s walking group. She plays an important role in providing another level of care for people like Manfred who have complex or chronic conditions, ensuring that the PCN’s services are integrated and available for those who need them.

It was Rhonda that connected Manfred with Rebecca Neveu, the registered dietitian who also works part-time out of the clinic. At his annual visit to his diabetes specialist, Manfred was told he had too many instances of low blood sugar. He knows the best way to manage his diabetes is with diet and exercise, so between those annual specialist visits, Manfred is committed to managing his own health, with the support of everyone at Bonnie Doon Medical Clinic.

“The PCN is a tremendous help to my family practice,” says Dr. Hamilton. He’s a strong supporter of the Medical Home concept, and believes the best care is holistic. Being a member of the Primary Care Network empowers him to integrate more levels of care for his patients.

Today, that care includes joining patients for a brisk walk. It’s an unconventional and welcome example of what’s special about family practice.

“We deal with the whole person, and it takes a team to deliver that,” says Dr. Hamilton, joining the group as they set out to walk their way to better health.