Advancing Nurse Practitioner Team-Based Care
Stronger nurse practitioner care, every day
Thames Valley Family Health Team continued to advance nurse practitioner-led team-based care as one of its most important access innovations in 2025-2026.
The model supports nurse practitioners serving as Most Responsible Providers (MRP), meaning patients receive care primarily from a Nurse Practitioner. This gives more people access to comprehensive, team-based primary care. Responsibilities are shared across nurse practitioners, physicians, nurses, interdisciplinary health professionals1, administrative staff, and community partners. The collaboration focuses on attachment, continuity, prevention, and whole-person support.
Supporting the Model
To support this work long-term, TVFHT created a Nurse Practitioner Transformation Lead role. The Lead embeds NP workflows into organizational operations, strengthens the sustainability of the model, and builds collegial partnership between NPs and physicians. They reinforce the value of nurse practitioner leadership in primary care transformation.
TVFHT also enhanced the role of interdisciplinary healthcare professionals in team-based care:
- RN prescribing started at two clinics. Specially trained registered nurses can now prescribe medications for common, lower-complexity issues. This includes renewing prescriptions or treating a certain ailments and infections without waiting for a physician or nurse practitioner approval. For patients, this means fewer steps and quicker access to needed treatment.
- Providers in Elgin received stepped care training to help match patients to the right level of service.
Supporting Patients
TVFHT implemented several tools developed by the project team to support patient care, including:
- Standardized intake materials
- A patient complexity tool that considers social determinants of health
- Patient Handbooks
- Patient resources
- Provider toolkits
- Care pathways
These tools help teams balance patient needs, provider capacity, and sustainable panel development.
TVFHT’s Nurse Practitioner Clinics
TVFHT Nurse Practitioners began acting as Most Responsible Provider at three clinics in the region:
- 460 Springbank Drive, London
- Elgin Community Health Hub, St. Thomas
- Health & Homelessness Team, London
Work started to open two more clinics and expand two current clinics through provincial access and attachment funding.
460 Springbank – London
This clinic expanded as part of a 2025 pilot to attach patients to nurse practitioners, while continuing valued services for Old South Family Health Organization patients, including:
- Women’s health appointments
- Same-day appointments
- Regular participation in the after-hours clinic
As of June 30, 2026, the clinic has attached 868 patients, many referred through Health Care Connect and community partners.
Elgin Community Health Hub – St. Thomas
Building on its 2024 launch, over the last year the team has supported:
- Attachment
- Centralized referral processes
- Respiratory therapy services
- Preventative cancer screening clinics, available to all residents of Elgin
The clinic welcomed 551 new patients as of June 30, 2026, with a goal of 800 by March 2027. Insights from Elgin’s supported attachment model are now informing care pathways in nearby regions.
Health & Homelessness – London
Based at 602 Queens Avenue and active in community settings, this team provided low-barrier, trauma-informed care for people experiencing homelessness and marginalization. The team ran 14 pop-up vaccination clinics, reaching 262 people and administering 400 vaccines. They also hosted cervical cancer screening clinics at community centres, and Community health prevention clinics.
The team’s work was recognized with two organizational honours:
- Nurse Practitioner Heather Kelly received the 2025 Living Our Values Award
- The Health & Homelessness Team received the 2025 Team Impact Award for removing barriers, building trust, and creating a model of outreach-based primary care that supports connection and stability.
The team presented the initiative’s success at the 2025 Association of Family Health Teams Ontario (AFHTO) Conference in a poster, “Equity in Action: Expanding Access to Primary Care.” The poster highlighted key data demonstrating the impact, including a noticeable decrease in calls to emergency medical services after the team began providing on-site care at the Centre of Hope.
Patient Story: Ray
Behind every attachment target is a person whose life changes when care becomes consistent, coordinated, and close to home.
After years of relying on urgent care and walk-in clinics to navigate his declining health, Ray finally found the support he had been looking for.
During his initial intake appointment, Ray felt “this was like home.” He says being a patient of a Nurse Practitioner is like “talking to your sister.”
Instead of sitting in a crowded waiting room, “now, I pick up the phone and get the next appointment,” he says. “I’ve got somewhere to go and somebody to listen to me and help me. It’s a huge weight lifted off my shoulder.”
“I recommend a Nurse Practitioner to everyone,” he says proudly.
For three years, Ray’s health was in a steep decline. Having survived six heart attacks, two mini strokes, a quadruple bypass, and gallbladder surgery, he had been living without a primary care provider in 2022 when his doctor retired. He was 60 at the time.
He heard about TVFHT’s Nurse Practitioner clinic through Ontario Health atHome and got himself on the list.
“Now it’s a huge difference” he says referring to those years when he was without a primary care provider. Ray’s NP was able to get his chart from the specialists he had seen in the past, review and make changes to some of his medication, and even get him drug samples since he was paying for his medications out of pocket.
The Impact of Team-based Care
Ray has found out the value of team-based care. He met with a social worker to support his mental health. He also met with a pharmacist to discuss how to quit smoking and to do a medication review of all the drugs he was taking. “The pharmacist sat me down and explained what they were going to do and how they were going to help me. She gave me all kinds of information.” Ray left armed with resources and tools on how to quit smoking. He remains smoke free today.
“Before, I couldn’t walk ten paces without being winded. And now, I can do everything.”
Thanks to his health team, the future looks bright for Ray. He is looking forward to being able to go fishing and keep up with his growing grandkids.
Ray’s story is one of many that capture what nurse practitioner-led care means at its best: continuity, trust, and a team that shows up. As TVFHT expands this model further, every attachment target reflects a real person getting real, consistent care. This is what strengthening care and expanding possibility looks like – one patient at a time.
Interested in learning more about becoming a patient of a TVFHT nurse practitioner clinic in Elgin, London, Middlesex, or Oxford? Reach out to the team, and learn more, at: www.thamesvalleyfht.ca/become-a-patient