The Patient's Medical Home in Nova Scotia
The Nova Scotia College of Family Physicians (NSCFP) is committed to advancing the principles of the Patient's Medical Home (PMH) and promoting a healthcare system that supports comprehensive, coordinated, and patient-centred family medicine.
Nova Scotia's Health Home model provides an opportunity to strengthen team-based primary care by bringing family physicians, nurse practitioners, nurses, and other health professionals together to support patients and communities. The success of team-based delivery depends on strong collaboration, continuity of relationships, and comprehensive, family physician-led care that responds to patients and their communities over time.
NSCFP advocates for a healthcare system in which every Nova Scotian has access to a family physician when needed, supported by a collaborative team of health professionals. Through advocacy, partnerships, and engagement with government and health system leaders, we work to advance policies and practice environments that support the PMH and a strong, sustainable future for family medicine in Nova Scotia.
Recognizing Excellence in Team-Based Family Practice
The NSCFP Patient's Medical Home: Outstanding Team-Based Family Practice Award recognizes practices that demonstrate the principles of the PMH through meaningful collaboration and patient-centred care.
We are proud to celebrate our award recipients and showcase examples of outstanding family practice in Nova Scotia.
Past Recipients
Middleton Collaborative Practice
Middleton
2026
Middleton Collaborative Practice (MCP) is the recipient of the Patient’s Medical Home: Outstanding Team-Based Family Practice Award. MCP exemplifies team-based family medicine through its strong culture of collaboration, commitment to comprehensive care, and responsiveness to the needs of its rural community.
Serving approximately 7,667 patients, MCP providers extend their expertise across multiple care settings, including inpatient units, emergency departments, long-term care, and community-based services. This approach strengthens continuity of care and improves access for patients throughout the region.
Collaboration is central to the clinic’s model. Weekly interdisciplinary rounds allow the team to discuss complex cases, coordinate care plans, and provide comprehensive, person-centred care. MCP also responds to the broader needs of its patients through initiatives such as a community cupboard for those experiencing food insecurity or financial hardship, as well as group education and support sessions addressing topics including grief and bereavement, postpartum support, and infant feeding.
The team continually adapts its services to meet the needs of its community and to improve access to care. Recent examples include advanced footcare and home blood draws for patients who face barriers to accessing services. MCP also uses its EMR to monitor population health indicators, identify gaps in care, and support quality improvement initiatives.
Through collaboration, innovation, and a commitment to meeting patients where they are, the Middleton Collaborative Practice demonstrates the impact of a strong team-based approach to family medicine and is a deserving recipient of the Patient’s Medical Home Outstanding Team-Based Family Practice Award.
Team Members
Dr. Leslie Riberio, Family Physician
Dr. Michele Saxon, Family Physician
Dr. Sarah Surette, Family Physician
Dr. Omorede Osayande, Family Physician
Dr. AC Silver, Family Physician
Dr. Nima Fomani, Family Physician
Dr. Yasmin Sadri, Family Physician
Dr. Alex Smith , Family Medicine Resident
Dr. Jenna Nauss, Family Medicine Resident
Dr. Laura Pickett, Family Medicine Resident
Dr. Olusegun Odebode, Family Medicine Resident
Michael Kiefl, Nurse Practitioner
Luca Harris, Nurse Practitioner
Sona Thankachan, Nurse Practitioner
Sarah O’Reilly, Family Practice Nurse
Pamela Carrier, Family Practice Nurse
Laura Ashbourne, Licensed Practical
Nurse Loralee Smith-McFarlane, Social Worker
Kate Wentzell, Registered Dietician
Tyler Marchbank, Occupational Therapist
Melanie Taylor, Admin Manager
Cyndi Morrell, Office Manager
Margo DeWolfe, Administrative Assistant
Lisa Fleet, Administrative Assistant
Shari Silver, Administrative Assistant
Kara Dobbs, Administrative Assistant
Tonie Hooper, Administrative Assistant
Nancy MacLean, Administrative Assistant
Megan Magarvey, Administrative Assistant
NSH Support
Emma Foote, Practice Facilitator
Hilary Cullen, Health Services Lead
Jennifer Kelday, Health Services Manager
Clare Health Centre
Meteghan Centre
2025
The Nova Scotia College of Family Physicians is proud to recognize Clare Health Centre as the 2025 recipient of our inaugural Patient’s Medical Home: Outstanding Team-Based Family Practice Award.
Located in the Acadian region of Nova Scotia, the Clare Health Centre has been a vital part of the community since opening its doors in 2008. The clinic embodies the principles of the College of Family Physicians of Canada’s Patient’s Medical Home model through a truly collaborative, team-based approach to patient care.
Clare Health Centre offers comprehensive, continuous, and coordinated care to approximately 10,000 patients in the Municipality of Clare and surrounding areas. Their interprofessional team is comprised of 11 family physicians, 1 nurse practitioner, 3 nurses, and 3 allied health professionals, all working together to improve health outcomes and patient experiences.
The clinic exemplifies the PMH vision by:
- Offering timely access to care through advanced access scheduling
- Supporting comprehensive care with a range of in-clinic and community services
- Maintaining strong relationships with patients and their families
- Using a EMRs and quality improvement initiatives to continuously enhance care delivery
- Prioritizing continuity and coordination through close collaboration among providers
This award celebrates the Clare Health Centre’s commitment to innovation, teamwork, and excellence in primary care – a true model of what family medicine can look like when it centers on the needs of patients and communities.
Dr. Michelle Dow, CCFP
Dr. Giselle Dugas, CCMF
Dr. Jean-Luc Dugas, CCMF, FCMF
Dr. Alain Blinn, CCFP
Dr. Erica Lasher-Coates, CCFP(EM)
Dr. Emma Leon, CCFP
Dr. Kristen Melanson, CCFP
Dr. Emma LeBlanc, CCFP
Dr. Joel Arsenault, CCFP
Dr. Dylan Engell, CCFP
Dr. Amanda Glenn, CCFP
Crystal Thibodeau, NP
Steven Baggs, RN-AP, Family Practice Nurse
Catherine Smith, RN, Family Practice Nurse
Nicole Meritt, Social Worker
Marsha Arnburg-LeBlanc, Dietitian
Amanda Thibodeau, RN, Diabetic Clinic
Jessica Eisener, Kinesiologist & Wellness Coordinator