Patients Collaborating with Teams (PaCT) takes a proactive, systematic approach to enable patients to manage their care when they have, or are at risk for having, multiple chronic diseases or other complex health needs. PaCT takes the next step in the patient’s medical home by furthering the panel and chronic disease management work already underway in PCNs and primary care clinics.

At the heart of PaCT, providers and their teams are supported to reach those patients that keep them up at night by shifting the conversation from, “What’s the matter?” to “What matters to you?”

  • Advances in evidence based medicine create opportunities to improve care for patients with complex health needs
  • Practice-level collaborative care planning approaches are effective in supporting patients with complex health needs
  • Research tells us that using team based care improves patient outcomes
  • ‘Many hands make light work’: when teams share skills and knowledge to care for those with complex health needs, the work is not as challenging for any one person
  • Alberta data indicates that many practices have a significant number of patients with complex health needs who do not seek adequate care
  • PaCT will build on panel identification and maintenance processes already embedded in practices and facilitate the spread of excellent care processes to all primary care practices.

PaCT Resources

Various tools and resources related to panel and continuity can be found using the links below: