Process for Referring People with Complex High Needs to Primary Care

Background on the Process for Edmonton and Area Agency Staff to Support Links to Primary Care Teams

The following processes were created in response to agencies and patients having problems finding a family doctor or medical home when there are certain complexities such as mental illness, addictions, homelessness and stigmatization.

Primary Care Networks (PCN) can help to support agencies in the Edmonton Zone working with complex patients. They are ready to connect patients with a family doctor and allied health professionals for ongoing health care. Becoming a PCN patient also provides access to a range of health services and helps to support service coordination with community agencies.

The process below gives a short visual guide for two ways to help a complex patient find an appropriate family doctor when they are ready. These referral pathways can be used by agency staff to navigate and support the engagement of complex patients with a suitable and accessible medical home. The processes below are staggered. The first process (see “start here”) is the usual process and should be tried first. If this does not work, the second process may be used to directly connect complex patients with a health care provider (see PCN Direct Referral Process).

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Click here to download referral process to primary care for people with complex needs.

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