Patient Medical Homes

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.

For patients

Through a PMH, patients have greater access to continuous, comprehensive, and coordinated primary care.

For doctors

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.

Get involved

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.