Updated November 17, 2023.
Creating freedom for family doctors so they can do the work they love to do, and what brought them into the medical profession in the first place.
A patient medical home (PMH) is a family practice that operates at an ideal level to provide longitudinal patient care.
It is the foundation of care delivery within primary care networks (PCNs) in local communities—the cornerstone of an integrated system of primary care community care.
A PMH has 12 attributes that define how a practice can support patients, including through team-based care.
As an ideal family practice, a PMH enables family doctors to:
- Access other health care providers to support quality patient care.
- Use accurate EMR data to increase proactive, preventative care.
- Get support for patients from health care teams located in the practice or in the community, and from networks of colleagues. Everyone can work to their strengths, and support and rely on each other to ensure patients get the best care.
- Participate in primary care networks to access a broader system of services and supports in the community.
Within a PMH, physicians (or sometimes nurse practitioners) as the most responsible care provider play a central role in leading and coordinating patient care.
Other primary care clinics, such as a community health centre or health authority-run clinic can also function as a PMH.
Through a PMH, patients have greater access to continuous, comprehensive, and coordinated primary care.
Within a PMH, family doctors can:
- Increase their ability to provide optimal care for patients, and conveniently access a full range of supports and services for patients.
- Spend more time on difficult diagnoses and strengthening patient relationships.
- Reduce the burden of caring for patients alone, which can help to prevent burnout.
- Increase the efficiency of the practice and streamline processes to maximize time, resources and capacity.
The FPSC is supporting family doctors to move toward the PMH model of care in three key areas of work:
- Team-based Care
Access other health care providers to support quality patient care.
- Panel management
Use patient data to inform and plan proactive care.
- Clinical networks
Get support from colleagues to provide continuous, comprehensive patient care.
- Primary care networks
Participate in a supportive network of local primary care services to increase comprehensive care.
International model, adapted for BC
The PMH model is being implemented and tested around the world, which has given BC a chance to learn from what others have done.
The 12 attributes of a patient medical home in BC are based on the College of Family Physicians of Canada’s framework and pillars.
The FPSC has adapted the PMH model to recognize strong partnerships and networks that have been established through the divisions of family practice, health authorities and community partners. The provincial model also takes into account the collaborative partnership between the Government of BC and Doctors of BC, represented by the FPSC, that is unique to BC.
Research and Evidence
- Practice Characteristics Matrix - Document
A guide that illustrates the continuum of the 12 attributes.
- Practice Characteristics Matrix - Poster
A large printable poster version of the guide to use at community events.
- Patient Experience Tool
An e-questionnaire that collects patients' perspectives on their visits to a GP's practice.