Sunshine Coast Division of Family Practice

Team-Based Care and Attachment - Our Strategies

Patient Navigator 

Patient Navigator (runs from April 20, 2015 to March 31, 2017) 

Attachment Assessment Clinic

  • This program has now ended. 

Cultural Competency

Team-based Incentives



  • Vulnerable unattached patients wanting a GP assessed & attached on priority basis as new GPs hired and as current GP capacity allows
  • Mobile support for high needs patients to help navigate the health system
  • Experiential training workshop for physicians
  • Monetary incentives to support GP recruitment

Short-term Outcomes

  • Improved care for vulnerable unattached patients
  • Improved experience of care for patients requiring extra supports
  • More coordinated care
  • Better supports for GPs
  • Increased competency when working with First Nations patients
  • Increased capacity of the physician team; ability to take on AAC priority patients and reduce impact of retiring GPs

Medium & Long-term Impacts

  • Better health outcomes
  • Reduced admissions and readmissions to ER
  • Increased cultural competency among GPs and improved care for First Nations populations
  • Increased primary care capacity
  • Increased patient satisfaction
  • Increased system sustainability
  • Supports the Triple Aim

Target populations

  • Unattached patients
  • Vulnerable/high-needs patients
  • First Nations patients
  • Family physicians
  • New family physicians
  • Community