Middleton Collaborative Practice recognized for outstanding team-based care

A shared commitment to each other and their community has earned Middleton Collaborative Practice provincial recognition for its approach to primary healthcare.

The team has received the 2026 Nova Scotia College of Family Physicians’ Patient’s Medical Home: Outstanding Team-Based Family Practice Award, recognizing its success in delivering collaborative, patient-centred care.

Serving approximately 7,667 patients, Middleton Collaborative Practice brings together family physicians, nurse practitioners, nurses, a social worker, dietitian, occupational therapist and administrative staff to provide comprehensive care. The team's approach reflects the collaborative, patient-centred care Nova Scotia Health is strengthening through more than 120 health homes across the province.

Dr. Michele Saxon joined the practice in 2010 and has spent the past 15 years helping to build a collaborative team focused on meeting the needs of its community. “This award is really a recognition of all the work that’s gone into building this shared philosophy over the years,” said Saxon. “We want to create something sustainable for our community, where providers want to come, work together and hopefully stay.”

That philosophy is clear in how the team approaches care. Each week, team members from different health professions gather to discuss patient needs, share ideas and plan their care together. Throughout the day, team members also rely on one another to ensure patients receive the right support.

Saxon sees the benefits of this teamwork first-hand. She shared the example of a patient with complex health needs who was preparing to leave hospital. Along with the patient's nurse practitioner, the clinic's occupational therapist and social worker had been helping address challenges with mobility and daily living. “Knowing that there are multiple people who know this patient and are invested in their care makes it much easier to feel confident that all aspects of their needs will be addressed,” said Saxon. “The goal is to help them live with dignity in their own home for as long as possible.”

Working together also helps the team identify gaps in care and find ways to better meet the needs of their community. They’ve developed a range of initiatives in response to local needs, including grief and postpartum education groups and a community cupboard for people experiencing food insecurity, among many others. Team members have also pursued additional training and certification to expand the support they can provide to patients.

Dr. Leslie Ribeiro, who trained at the clinic before joining the practice in 2016, said the team's willingness to recognize and respond to these needs is a source of pride. Behind these initiatives is a workplace culture where team members are encouraged to use their full range of skills and expertise.

“Each of us has a different scope of practice that complements the others and helps ensure patient care needs are met,” said Ribeiro. “I think I’m just proud in general that the team steps up to meet the needs of the community.”

From nurses independently managing routine well-baby visits to physicians providing cross-coverage for one another, team members share responsibilities and draw on each other's expertise. This approach helps patients receive timely care while benefiting from the knowledge and perspectives of different healthcare professionals. It's an approach the team values.

“We are celebrated for our strengths, diverse expertise, collaboration, and community engagement,” wrote registered nurses’ Sarah O’Reilly and Pamela Carrier and licensed practical nurse Laura Ashbourne.

The Middleton team was among those honoured at the Nova Scotia College of Family Physicians’ Family Medicine Awards Banquet on Oct. 23 at Pier 21 in Halifax.

“It’s a nice pat on the back to have the work we do recognized, but we don’t do it for recognition. We do it for the benefit of our patients,” said Ribeiro. “Hopefully, this award will inspire others to develop collaborative practices. I think this approach helps provide more comprehensive care than any one provider can offer alone.

“It’s just a great work family, and we’re very proud of the work that we do.”

Photo of (L-R) Loralee Smith-McFarlane, social worker; Dr. Jenna Nauss, family medicine resident; Sarah O’Reilly, family practice nurse; Dr. AC Silver, family physician; Dr. Sarah Surette, family physician; Pamela Carrier, family practice nurse; Kate Wentzell, registered dietitian; and Dr. Leslie Ribeiro, family physician.

Missing from photo: Dr. Michele Saxon, Dr. Omorede Osayande, Dr. Nima Fomani and Dr. Yasmin Sadri, family physicians; Dr. Alex Smith, Dr. Laura Pickett and Dr. Olusegun Odebode, family medicine residents; Michael Kiefl, Luca Harris and Sona Thankachan, nurse practitioners; Laura Ashbourne, licensed practical nurse; Tyler Marchbank, occupational therapist; Melanie Taylor, admin manager; Cyndi Morrell, office manager; Margo DeWolfe, Lisa Fleet, Shari Silver, Kara Dobbs, Tonie Hooper, Nancy MacLean and Megan Magarvey, administrative assistants; Emma Foote, practice facilitator; Hilary Cullen, health services lead; and Jennifer Kelday, health services manager.