Heart of Health: Connecting care through collaboration - How Nova Scotia Health is bringing healthcare home

When Jennifer Boswall walks into the Centennial Collaborative Practice in Kentville, she’s not just stepping into a clinic — she’s stepping into the future of collaborative care in Nova Scotia.

Jennifer is a registered nurse and care coordinator with Nova Scotia Health’s Continuing Care program. Her role is part of an innovative initiative that’s making it easier for Nova Scotians to access the care they need, right from their primary care provider’s (family doctor or nurse practitioner) office.

Launched as a pilot in 2023 in Kentville, Bridgewater and Yarmouth, this collaboration placed care coordinators into Health Homes and Primary Care Clinics to improve cooperation between professions. The pilot showed many positive impacts for both patients and providers, which led Nova Scotia Health’s Primary Healthcare and Chronic Disease Management Network and Continuing Care teams to explore expanding the model to select clinics across the province.

“This shift in how we deliver care supports our broader vision of evolving ‘Health Homes’ — a model of care that emphasizes collaboration, continuity and patient-centered care,” said Noella Whelan, senior director, Nova Scotia Health Primary Healthcare and Chronic Disease Management Network.

Care coordinators manage a caseload of clients with complex needs that require ongoing community-based support and liaise between the continuing care and clinic teams using a Home First approach. Their goal is to help people connect more easily with home care, community care services and long-term care. 

“This initiative aligns with our goal to support more Nova Scotians in receiving care at home by improving access to continuing care services,” said Glenda Keenan, senior director, Nova Scotia Health Continuing Care.

Recovering at the place you call home can often lead to a faster and more comfortable recuperation from illness or a hospital stay. Being in a familiar environment reduces the risk of hospital-acquired infections, promotes better sleep and mobility and supports greater independence.

This new model of care aims to enhance coordination between healthcare providers, facilitating earlier access to Continuing Care programs and services. The care coordinator works with patients to assess their care needs, arrange home care, respite or other services to ensure the person receives the right care, in the right place at the right time.

“Pairing continuing care with primary care has fundamentally changed my practice,” said Dr. Dwight Klippenstine, physician co-lead, Centennial Collaborative Practice. “It’s prevented unnecessary hospital admissions and allowed us to set up timely, effective services to keep people healthy in their own homes.” 

Care coordinators are now working in 16 clinics across Nova Scotia, including offices in Dartmouth, Halifax, Bedford/Sackville, Windsor, Hantsport, Truro, New Glasgow, Springhill, Sydney, Antigonish, Kentville, Yarmouth and Bridgewater. 

Nova Scotia Health continues to evaluate and monitor this approach to delivering primary healthcare and continuing care.

Jennifer splits her time between two Kentville clinics — Centennial Collaborative Practice and Core Family Health — where she works closely with family physicians, nurse practitioners, nurses and allied health professionals such as dieticians, physiotherapists and occupational therapists. Together, they identify patients who may benefit from continuing care programs and services and help them understand their options.

“It is a pleasure working with a knowledgeable, professional, cohesive group of dedicated health professionals and seeing the rewards of our collaboration benefit the patients and families we serve,” Jennifer said. “This timely access, interprofessional expertise and sharing of health knowledge and information has built a more comprehensive, cohesive healthcare team that can pinpoint and focus on areas of patient concern and develop solutions to address those concerns.”

As Nova Scotia continues to transform its healthcare system, initiatives like this one are proving innovation doesn’t always mean high-tech — it can be as simple and powerful as putting the right people in the right place.

“(Jennifer) has given us valuable insights to bridge the gap between clinic and home, enhancing patient care and health outcomes. Integrating a continuing care touchpoint in our practice connects patients with services earlier, helping them stay healthier at home longer and ensuring continuity of care through ongoing assessment of their changing needs,” said Centennial Collaborative Practice nurse practitioner Ciara O’Sullivan.

Opportunities to enhance how we deliver care continue to be explored as Nova Scotia Health works to provide the best care to Nova Scotians.

“The ability to communicate quickly, either face-to-face or through our EMR (electronic medical record) creates the dynamic to provide the most effective care for each client in real time. I cannot imagine practising primary care going forward without this connection to Continuing Care," Dwight said.

If you or a loved one needs help staying at home or support after a hospital stay, Nova Scotia Health’s Continuing Care team is here to help. Call 1-800-225-7225 or visit www.nshealth.ca/continuing-care.

For more information about Health Homes in Nova Scotia, visit www.nshealth.ca/health-homes.

Photo of (L-R) Dr. Dwight Klippenstine, physician co-lead; Jennifer Boswall, care coordinator and Ciara O’Sullivan, nurse practitioner at Centennial Collaborative Practice.