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Oct 08, 2025
This blog post is based on the cover story originally published in the October 2025 issue of doctorsNS magazine.
Practising in a community health home (CHH) within a fully collaborative care setting has been transformative for Dr. Jillian DiPenta. Working closely with the Mentor Clinic team for the past two years has significantly enhanced how she delivers care.
Dr. DiPenta is one of two family physicians at Mentor Clinic; she joined the clinic along with Dr. Shauna Archibald in fall 2023. Dr. DiPenta says the CHH’s coordinated approach to care has led to better patient outcomes and helps providers address health concerns before they escalate.
“I’m able to spend more time with patients, focus on prevention, and offer care that is truly comprehensive and continuous,” she said.
Mentor Clinic was conceived by Dr. John Ross, a former ER physician, and Susan Helliwell, the CEO of the PRAXES Medical Group. Over the last two years, the clinic that started with Dr. Ross, a nurse practitioner (NP) and a family practice registered nurse (RN) providing mobile primary care in rural Nova Scotia has evolved.
The clinic is now located in extensive offices on Gladstone Street in Halifax, where patients can receive care from Drs. DiPenta and Archibald, plus five NPs, a registered dietitian, a certified exercise physiologist, an occupational therapist, a physiotherapist, family practice RNs and a social worker – all supported by a team of medical office administrators.
At Mentor Clinic, the goal is not only to provide access to primary care providers, but also to truly engage patients in their own care, improve their knowledge of how their bodies work, and identify people who are trending toward various diseases and intervene early. The clinic focuses on team-based care and functional collaboration.
As its name suggests, Mentor Clinic offers continuous and multi-directional learning opportunities.
“We learn from our patients, we teach them, we learn from one another and we have learners in various disciplines work with us,” Dr. Ross said. “It is a mentoring culture and environment. Curiosity and the willingness to try new things is core.”
That innovative, collaborative and patient-centred model of care is deeply inspiring to Dr. DiPenta.
“I want to contribute to a model where we prevent illness before it begins, empower patients in their health journey and support each other as colleagues,” Dr. DiPenta said.
The entire Mentor Clinic team coordinates to provide patients with timely, holistic care, she said, often avoiding unnecessary ER visits. For example, a patient with an acute issue can access same-day urgent care with a physician or NP. That provider might refer the patient to the clinic’s physiotherapist or occupational therapist. If the patient requires help navigating the broad range of social supports, housing and financial services, the in-house social worker can be brought in.
Those with chronic conditions, such as diabetes, can access regular check-ins with a primary care provider, nutrition counselling with the clinic’s dietitian, exercise support from the clinical exercise physiologist, and goal-setting with nursing and administrative support.
The collaborative model makes it easier to advocate for patients, said Aly Pickard-Tattrie, the clinic’s occupational therapist. “Having everybody right next door means there is much less siloed work. There’s no delay in getting the information to where it needs to go. You really get to dive into your full scope and support patients with their full set of needs.”
The team regularly holds complex case rounds, says Emma Gillam, an NP who has been with the clinic since day one. This can provide valuable insights.
“Often, when faced with a challenging case, our conversations shift from what more can we test, prescribe or do clinically, to understanding the barriers the patient is facing in achieving their health goals,” said Ms. Gillam. That shift in thinking is powerful. “Together we explore how to reduce those barriers, whether they’re social, psychological or systemic. Our in-house interprofessional team plays a critical role in assessing and addressing them.”
“Patients commonly express they feel their quality of life improve due to access to our interprofessional team and the resources available,” reported Joy Chiekwe, the clinic’s exercise physiologist. “I get to hear about a new sense of hope to live a life without chronic pain, mobility issues or limitations of their functional capacity.”
Patients feel empowered, supported and connected, said Dr. DiPenta. “They benefit from continuity and shared accountability for their health outcomes.”
Building relationships and communication pathways within the Mentor Clinic team takes time, said Dr. DiPenta, but it pays off in better patient outcomes, greater efficiency, and higher levels of satisfaction for patients and providers.
“I now leave work feeling more fulfilled and energized. I feel supported, both professionally and personally, and that translates into better care for my patients.”
