Mosaic PCN Report to Community
August 2026
Data presented throughout this report is from FY 2025-26.
What Is Mosaic of Care?
This report, Mosaic of Care, is a dynamic resource that embodies Mosaic Primary Care Network's (PCN) commitment to transparency and adaptability as we address the community's evolving needs. It focuses on four key priorities:
Pathways to Patient Care
Improving access to care for underserved individuals and patients without a regular primary care provider.
Supported Providers, Strengthened Care
Supporting primary care providers through resource sharing, quality improvement projects, and enhanced care delivery systems.
Partnerships for Patient Progress
Collaborations across the Calgary Zone, along with our own community and clinical partnerships, to amplify our impact and advance our progress.
Collaborative Care
Implementing team-based approaches that prioritize holistic wellness through multidisciplinary teams.
At the outset, you’ll find an introduction to our organization, an explanation of what we mean by "medical home," and insights into the patients we serve. To make our report as accessible as possible, we've also included a dedicated section, Prescription for Understanding, to clarify common terms and acronyms.
What is Mosaic Primary Care Network?
Who We Are
Mosaic Primary Care Network (PCN) is a group of family doctors, nurse practitioners, and healthcare professionals providing primary health care to communities in northeast and southeast Calgary.
Community Impact
Our network of 480+ family doctors and nurse practitioners serves over 492,000 residents, delivering innovative, culturally sensitive care at no cost.
Strategic Coverage
Our member clinics serve the urban area east of 14 St W, from the Bow River to the eastern city limits, and from the northern city limits to Anderson Road/114 Ave SE.
Collaborative Healthcare
As a non-profit organization, we create an integrated healthcare experience that combines medical expertise with local insights to meet our community's unique needs.
Where to Find Us
Mosaic PCN offers services at our Sunridge Mall Clinic (Calgary, Alberta), providing streamlined care in an accessible location. This has enhanced collaboration and integrated patient care while maximizing resource efficiency. Learn more.
Easily Accessible
Located on Calgary's C-Train line with free parking and transit options, making healthcare more accessible to our community.
Enhanced Collaboration
Uniting after-hours care, our ACCESS clinic, and multidisciplinary healthcare teams provide seamless care coordination.
Community-Centered Design
Inspired by the Bow River, our new clinic serves as an inclusive gathering space reflecting our city's diversity.
Designed With Community Input
Developed through engagement with our staff, patient advisory group, and community partners to address everyone's needs.
Mosaic's Vision, Mission, and Values
In June 2024, we proudly launched Mosaic PCN's refreshed Vision, Mission, and Values-cornerstones of our organization's future. Together, they provide clarity, cohesion, and a unified direction essential for navigating challenges and achieving sustainable success.
Our Vision
Achieving excellence in primary healthcare outcomes within our diverse neighbourhood.
Our vision serves as a beacon for where we aim to go, providing clear direction and guiding our strategic planning and decision-making.
Our Mission
Your partner in providing exemplary healthcare experiences within our evolving communities.
Our mission defines our core purpose, aligning daily operations with broader goals and ensuring consistency in delivering exceptional care.
Our Values
Embrace Diversity; Build Community; Lead with Compassion; Drive Innovation
Our values guide our behaviors, set ethical standards, and provide a moral compass for decision-making while fostering a sense of belonging for employees.
Primary Care Starts with the Medical Home
What is a Medical Home?
Primary care is the first point of contact people have with the health system. The programs and services provided by Mosaic PCN are delivered in partnership with your primary care provider, designed to support the concept of a Medical Home.
Your First Point of Contact
A medical home is where patients feel most comfortable coming for their health needs (typically a medical clinic with care provided by a doctor or nurse practitioner).
A Team-Based Approach
The Patient's Medical Home (PMH) brings together an interdisciplinary team to provide high-quality, comprehensive, compassionate, and timely care tailored to each patient.
Connected to Your Community
Depending on your care needs, your primary care provider can connect you to various healthcare providers and services that support your Medical Home.
Why It Matters
Having a Medical Home isn't just convenient — it leads to measurably better health outcomes for individuals, families, and communities. People who are connected to their primary care provider and visit them regularly experience real, lasting benefits.
Continuity of Care
Seeing a consistent provider builds trust and a deeper understanding of your health history — leading to more accurate diagnoses, better-informed decisions, and stronger long-term health outcomes. Your care team knows you, not just your chart.
Fewer Emergency Visits
Patients with a Medical Home are significantly less likely to rely on emergency departments for care. With timely access to their care team, issues are addressed early — reducing stress on patients, families, and the broader health system.
Chronic Disease Management
Ongoing relationships with a care team help patients manage conditions like diabetes, hypertension, and heart disease more effectively. Regular monitoring, early intervention, and coordinated support lead to better control and fewer complications.
Health Equity
Medical homes help reduce healthcare disparities by ensuring underserved populations — including seniors, newcomers, and low-income families — have consistent, dignified access to care. Everyone deserves a place where they feel known and supported.
Longer, Healthier Lives
Evidence shows that patients live longer and are healthier when supported by their primary care provider and a healthcare team in their Medical Home. The relationship between patient and provider is one of the most powerful tools in medicine.
Mosaic PCN & Primary Care
Mosaic PCN doesn't replace your primary care provider — we work alongside them. Through dedicated teams, embedded health professionals, and system-wide partnerships, Mosaic PCN strengthens the Medical Home so patients receive the right care, at the right time, from the right provider.
Practice Excellence
The Medical Home Practice Excellence (MHPE) team delivers timely, customized support to each provider — helping them achieve and sustain high standards in their Patient Medical Home practice through targeted quality improvement initiatives.
Expanding the Care Team
Mosaic PCN embeds multidisciplinary health professionals — including nurses, mental health therapists, kinesiologists, and dietitians — directly alongside primary care providers, so patients receive comprehensive care without leaving their Medical Home.
Connecting Patients to Care
Through programs like our ACCESS Clinic, ICON, and SPROUT, Mosaic ensures patients — including those without a primary care provider — are connected to timely, appropriate, and coordinated care.
System-Wide Partnerships
Through health system partners and community engagement initiatives, Mosaic supports patient navigation and transitions in care - reducing gaps, improving communication, and strengthening the broader healthcare system across the Calgary Corridor.
Strengthening the Medical Home
Supporting Providers, Strengthening Care
Our Medical Home Practice Excellence (MHPE) team collaborates with primary care providers to enhance quality of care through targeted improvement initiatives. We ensure each provider within Mosaic PCN receives timely, customized support to achieve excellence in their unique Patient Medical Home (PMH) practice.
Supporting Providers, Strengthening Care
Mosaic PCN supports the Patient Medical Home (PMH) model through its Medical Home Practice Excellence (MHPE) team. A PMH is more than a clinic — it's a comprehensive care model where patients connect with the right support at the right time, led by a primary care provider and working alongside a multidisciplinary team to deliver patient-centered care throughout every life stage.
Language Access Support
Provides essential translation services with impressive growth in 2025-26: 555,117 minutes of usage, supporting nearly 90 different languages with 33,181 calls.
Quality Improvement
Through evidence-based practices and evaluation tools, we support the optimization of clinic processes to enhance patient care and achieve better health outcomes.
Care Delivered by Mosaic
Collaborative Care for Holistic Wellness
Integrated Healthcare Team
Our comprehensive care team includes primary care nurses, dietitians, pharmacists, social workers, mental health therapists, community health navigators and kinesiologists working together to support your wellness journey.
Flexible Care Options
Access our services through medical home referrals, a centralized Mosaic PCN clinic, or convenient phone and video consultations for personalized health support.
Personalized Support
From brief interventions to long-term case management, we tailor our approach to patients' unique health goals and challenges.
Our Multidisciplinary Team Services
Mental Health Services
- Short-term counselling (up to 6 sessions)
- Evidence-based treatments including CBT and solution focused therapy
- Support for depression, anxiety, grief, and loss
Social Work
- Resource navigation and benefits application assistance
- Support for life transitions and basic needs
- Community service referrals
Primary Care Nurses
- Chronic disease management
- Certified Diabetes education
- Health monitoring and education
Pharmacy Services
- Medication review and optimization
- Cost-effective medication planning
- Specialized respiratory and diabetes care
Dietitian Services
- Chronic disease nutrition management
- Culturally sensitive counselling
- Specialized dietary support
Kinesiology
- Certified Exercise Physiology services
- Customized physical activity planning
- Pain and mobility management
Community Health Navigators
- Personalized navigation of care and access available services in the community
- Empower patients to achieve self-management and quality of life goals
BY THE NUMBERS
90.8%
Patient Satisfaction Rating
Based on 2,451 total responses
70K
MDT Patient Visits
Total one-on-one patient visits with MDT*
Pathways to Patient Care
18.5%
Of all provider visits conducted virtually
70K
Multi-Disciplinary Team Visits
8.8K
Physician / NP Visits
Pathways to Patient Care
Through the ACCESS Clinic and its programs and services, our goal is to help improve patient outcomes and reduce the strain on the healthcare system.
ACCESS Clinic
Mosaic PCN's ACCESS Clinic is an extension of a patient's medical home, providing care when their own provider is unavailable, including after-hours support, services for patients without their own provider, and women's health services. ACCESS also works with system partners to help manage Emergency Department overcrowding and support earlier discharge from hospital. In collaboration with HealthLink (811), Peter Lougheed Centre, and Primary Care Alberta, the clinic helps ensure patients receive the right care, at the right time, from the right providers.
Clinic Hours & Referrals
- Monday – Friday: 9:00 a.m. – 9:00 p.m.
- Weekends/Holidays: 8:30 a.m. – 4:30 p.m.
- Referrals can be faxed at any time and are reviewed during clinic hours
- Note: The ACCESS Clinic is not a walk-in clinic.
Key Benefits
Timely Access
Patients are typically seen within 24 hours for semi-urgent or episodic health needs.
Continuity of Care
Chart notes are returned to the referring provider, ensuring seamless follow-up and coordinated care.
Reduced Administrative Burden
Reduces the workload for clinic teams by managing semi-urgent cases efficiently and effectively.
ICON: Integrated Care Optimal Navigation
The ICON program connects patients without a primary care provider (PCP) to the care they need. Our Primary Care Navigation Nurses (PCNN) help with conducting comprehensive health assessments, guiding patients through available services, and empowering them to establish a medical home.
How It Works
Health Assessments
Primary Care Navigation Nurses (PCNNs) conduct comprehensive health assessments.
Service Navigation
PCNNs guide patients through available healthcare services.
Establishing Care
The program empowers patients to connect with a long-term primary care provider.
Personalized Support
Tailored support helps patients manage their health effectively.
ICON: Integrated Care Optimal Navigation
6,042
Patient Appointments
Connecting patients without a primary care provider to the care they need — one appointment at a time.
SPROUT: Supporting Mothers and Newborns Without Attachment
SPROUT is a referral-based NP led program, focused on offering timely medical follow-up for postpartum and newborn patients without a primary care provider. Our dedicated team provides expert care and support during the first six weeks of postpartum and newborn care.
How It Works
Discharge Information
Upon discharge from the hospital, patients receive handouts with information about the SPROUT Program and service location.
Appointment Scheduling
The SPROUT Program contacts patients directly to schedule an appointment.
Provider Notification
Referring providers receive notification of acceptance and a discharge summary after patients complete the program.
SPROUT: Supporting Mothers and Newborns Without Attachment
What SPROUT Offers
Multidisciplinary Referrals
Referral to multidisciplinary services, as needed.
Language Access
Language Line available to support patients in their preferred language.
Program Milestones
Unique Patients Supported
Through the SPROUT program in 2025-26.
Patient Referrals
To the ICON program to support attachment to a primary care provider.
Partnerships for Patient Progress
Community Engagement & Access
Mosaic PCN actively engages with the community to ensure accessible and equitable healthcare for all, focusing on our most vulnerable populations. Our initiatives empower individuals with health system knowledge and break down barriers to care.
Community Outreach & Education
- 13 health navigation workshops delivered to vulnerable communities
- 9 community events attended to raise awareness and connect residents to care
- ~600 vulnerable individuals reached across the Greater Forest Lawn area
- Main partners: The Alex Community Health Centre, Women’s Centre, Gateway, Punjabi Community Health Services, Salvation Army, Brown Bagging for Kids, and Alberta Healthy Living.
Reducing Barriers to Access
- 6 key social and health agencies with direct referral pathways
- Onsite navigation support provided at local agencies to guide patients through the system
- Barriers addressed: language, transportation, and health system navigation
- Clinical staff trained and equipped with a comprehensive external resource database
Calgary Zone Partnerships
Mosaic PCN works in partnership with other PCNs in the Calgary Zone across the following three areas to improve access, coordination, and equity in primary care.
Specialist Link
A tele-advice and clinical pathway service connecting primary care providers to specialists across the Calgary Zone, supporting informed care decisions without unnecessary referrals.
Coordinated Attachment Hub
A zone-wide initiative to connect patients without their own provider to primary care providers, reducing gaps in access and supporting more equitable patient attachment across the region.
Truth and Reconciliation in Primary Care
Ongoing collaborative work to advance culturally safe and unbiased care for Indigenous communities, including provider training and community clinic support.
Prescription to Understanding
A guide to Mosaic PCN's terminology and acronyms
- CHN - Community Health Navigator
- CPS - Clinical Projects Specialist
- ED - Executive Director
- EMR Specialist - Electronic Medical Records Specialist
- Kin - Kinesiologist
- LPN - Licensed Practical Nurse
- MHT - Mental Health Therapist
- MHPE - Medical Home Practice Excellence (team)
- MPCN - Mosaic Primary Care Network
- MOA - Medical Office Assistant
- NP - Nurse Practitioner
- PA - Physician Assistant
- PCC - Primary Care Coordinator
- PCM - Primary Care Manager
- RD - Registered Dietitian
- RN - Registered Nurse
- Rx - Pharmacist
- SW - Social Worker
- PCNN - Primary Care Navigation Nurse
- CDM - Chronic Disease Management
- CII/CPAR - Community Information Integration/Central Patient Attachment Registry
- EAP - Employee Assistance Program
- MHPE - Medical Home Practice Excellence
- ACCESS - Access and Continuity of Care Extended Services
- ICON - Integrated Care & Optimal Navigation
- SPROUT - Supporting Postpartum Mothers and Newborns without Attachment
- AIM - Access Improvement Measures
- CME - Continuing Medical Education
- EMR - Electronic Medical Record
- KPI - Key Performance Indicators
- MDT - Multidisciplinary Team
- PBH - Partners for Better Health
- PHC - Primary Health Care
- Unattached - individuals who do not have a family doctor or nurse practitioner for routine, ongoing primary health care.
Thank You
Thank you for taking the time to review Mosaic PCN's Mosaic of Care. For any questions, please don't hesitate to reach out to the Mosaic PCN Communications team at [email protected].
Mosaic of Care