Silverado Medical Clinic

Silverado Medical Clinic is a community-based primary care practice in Calgary that uses a team-based approach to improve diabetes care within the Patient Medical Home model. Recognizing opportunities to strengthen consistency in evidence-based diabetes management, the clinic developed a quality improvement initiative that combines physician leadership, nursing expertise, population health approaches, and proactive patient outreach.

The initiative focuses on identifying patients whose diabetes care may not be fully optimized and providing comprehensive assessment, follow-up, and coordination to prevent complications and improve long-term outcomes.

Our Team

Team members recognize their role through shared responsibility for the patient’s diabetes care and clearly defined complementary functions.

Family Physician

Provides overall clinical oversight
Reviews patients identified as needing additional support
Initiates or adjusts treatment plans
Manages complex clinical decision-making

PCBH Registered Nurse

Conducts comprehensive diabetes assessments
Identifies care gaps using the Diabetes Canada ABCDESSS framework
Supports patient engagement and education
Coordinates screening and investigations
Facilitates follow-up and communication between patients and providers

Team Workflow

Patients are identified through EMR population health searches and chart review.
Eligible patients are invited to participate in a comprehensive diabetes assessment.
The PCBH Registered Nurse conducts a structured one-hour assessment.
Patients with identified care gaps are referred back to their family physician.
The care team coordinates follow-up interventions, screening, and preventive care.
Patients are reassessed to monitor progress and optimize outcomes.

The model is grounded in the principle that comprehensive diabetes care is most effective when multiple members of the primary care team contribute their expertise toward a shared goal.

Team-based Care Solution Impact

Diabetes Canada ABCDESSS Framework
A key component of the model is the use of the Diabetes Canada ABCDESSS framework, which provides a structured approach to comprehensive diabetes care:

Framework Component Focus Area
A A1C
B Blood Pressure
C Cholesterol
D Drugs for cardiovascular risk reduction
E Exercise and Healthy Eating
S Self-management Support
S Screening for Complications
S Smoking Cessation and Support

The framework helps the team systematically identify care gaps, prioritize interventions, and ensure recommended preventive care and screening activities are completed.

Population Health Approach
The initiative also demonstrates the value of using electronic medical records as a population health management tool by:

Identifying patients who may benefit from additional support
Tracking quality indicators

The project highlighted opportunities to further improve EMR coding and reporting capabilities to increase efficiency and scalability.

Impact and Outcomes
Benefits for Patients
The team-based approach has helped strengthen:

Identification of diabetes care gaps
Access to comprehensive diabetes assessments
Coordination of preventive care and complication screening
Follow-up and ongoing disease management

Benefits for Providers
The model enables providers to:

Work at the top of their scope of practice
Share responsibility across the care team
Use structured assessment tools to support evidence-based care
Improve continuity and coordination within the Patient’s Medical Home

Success Factors
The team attributes its success to:

Clearly defined roles and responsibilities
A shared focus on patient outcomes
Use of the Diabetes Canada ABCDESSS framework
Strong collaboration between physician and nursing team members
Population health approaches supported by EMR data

Patient Experience

What Team-Based Care Looks Like for Patients
Patients experience team-based care through coordinated support from both their family physician and the PCBH Registered Nurse.
Rather than relying solely on traditional physician appointments, patients benefit from:

Proactive outreach and follow-up
Comprehensive diabetes assessments
Coordinated care planning
Support in completing recommended screening and investigations
Improved monitoring for complications such as diabetic retinopathy and peripheral neuropathy

Patients see multiple members of their care team working together, communicating around identified needs, and ensuring that preventive and chronic disease management activities do not fall through the cracks.

Our Advice

Testimonial

“Diabetes is a team effort and we can help reduce future complications together.”

Key lesson learned:
Comprehensive chronic disease management cannot always be achieved during physician appointments alone. Engaging multiple members of the primary care team allows practices to deliver more proactive, coordinated, and patient-centred care while helping ensure recommended prevention and screening activities are completed.

To learn more about this framework and the research behind the team, please download the research report.