Abstract

This article describes an innovative organization-spanning collaboration between primary care and acute care in Calgary to support continuity of care for patients with complex needs. Mosaic Primary Care Network provides funding for a primary care navigation nurse to work at the Peter Lougheed Centre, an Alberta Health Services hospital. This role supports hospital in-patients with discharge planning, linking to family physicians and connecting to programs that provide support in the community to vulnerable populations. The commitment of leadership from both organizations was critical for getting this unique role implemented.