Collaborative Care
Professional Standards Regarding Collaborative Care
Preamble
The College recognizes that healthcare is increasingly delivered by teams of professionals, often of various disciplines, that include physicians.
This standard identifies the independent professional responsibilities of physicians working in team-based, collaborative care settings.
In these settings, quality of care and continuity of care are achieved by the effective co-ordination and sharing of information and responsibilities between the various providers.
As these models of care continue to evolve, the College will regularly revisit the language of this standard.
Professional Standards
When practising in a collaborative care clinic, physicians have the following independent professional responsibilities:
Responsibilities to the patients
- Physicians must ensure that the patient understands whether their primary provider is the physician, another provider within the team, or the clinic itself.
| Primary provider refers to the individual or entity to whom or to which the patient is attached. In some arrangements the patient is attached to a specific physician or provider. In other arrangements, the patient is attached to the collaborative care clinic itself. |
Responsibilities for the systems within the collaborative care clinic
- Physicians who choose to work in collaborative care clinics must take reasonable steps to ensure the administrative systems of the clinic enable reasonable and appropriate medical care for their patients.
| The right of patients to high quality care is not to be compromised by the model of care delivery. Collaborative care clinics need to have administrative systems in place to maintain a complete record of all care provided by the clinic, and to allow for continuity of care, and follow-up and review for investigations. |
Responsibilities to the team within the collaborative care clinic
- Establish and maintain constructive relationships with physicians and other colleagues in the health care professions to support relationship-centred collaborative care; and
- Engage in respectful shared decision-making with physicians and other colleagues in the health care professions.
Definitions
Collaborative care clinic is a clinical setting or service in which the responsibility to deliver healthcare is shared by a team of two or more healthcare providers. Within a collaborative care clinic, access to the patient’s healthcare information may extend to regulated health professionals and their delegates within their circle of care or on a need to know basis.
Patient roster and continuity of care are for purposes of rostering or continuity of care, the patient may be attached to the clinic itself and not attached directly to an individual provider within the clinic.
Resources
College of Physicians and Surgeons of Nova Scotia
- Professional Standards and Guidelines Regarding Charting
- Professional Standards Regarding Transfer of Care
- Professional Standards Regarding Temporarily or Permanently Closing a Medical Practice
- Professional Standards Regarding Referral and Consultation for Patients with a Family Physician
Canadian Medical Protective Association
- Collaborative Care
- Results and expectations: test follow-up and the office-based family physician
- Walk-in clinics: Unique challenges and medico-legal risks
- Collaborative Care Setting
- Collaborative care: A medical liability perspective
Royal College of Physicians and Surgeons of Canada
Nova Scotia Health
Doctors Nova Scotia
Acknowledgements
This standard was informed by the College of Physicians and Surgeons of Alberta’s Continuity of Care practice standard and the College of Physicians and Surgeons of British Columbia’s Primary Care Provision in Walk-in, Urgent Care and Multi-registrant Clinics.
Document History
Approved by the Council of the College of Physicians and Surgeons of Nova Scotia: October 17, 2025
Date of next review: 2028