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Contact usAn innovative navigation program that connects patients being discharged from Calgary’s four urban hospitals with follow-up care and support has passed a major milestone: Recently completing its 1,000th request for follow-up care.
The service offers a single-entry point for acute care to connect patients requiring post-discharge care with PCN or community services. It was launched in July 2024 and is coordinated by a nurse navigator in partnership with Calgary-area PCNs.
“The navigation program is a great example of acute care and primary care working together to provide seamless care to patients as they transition from hospital to home,” said program manager Joe Kwan. “The program is continuing to evolve, and we are exploring expansion to support other populations, such as pediatrics.”
It is now scaled across all units in the four urban hospitals after beginning as a pilot with six acute care units. An initial manual process was replaced with an electronic system in August 2025 that uses Connect Care to process requests.
Patients who consent to being part of the program are contacted by a coordinator to better understand their needs and how to link them to services, which could include follow-up with a provider, connections to PCN programs or teams, links to community services or attachment to a family doctor or nurse practitioner.
Ninety per cent of patients are contacted within seven days of discharge, and satisfaction surveys show 91 per cent of patients felt the coordinator recommended the most appropriate resources to a “large or extremely large degree.”
The navigation coordination program is part of the Calgary Zone’s coordinated attachment hub, which connects residents with physicians or nurse practitioners as part of the Alberta Find a Provider “Help Me” service.
For more information, contact [email protected].