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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 in an integrated system of primary and community care and primary care networks (PCNs) in local communities.
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:
- Use accurate patient 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 (PCNs) 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, GPs 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 GPSC is supporting family doctors to move toward the PMH model of care in four key areas of work:
- Panel management
Use patient data to inform and plan proactive care.
- Team-based care
Access other health care providers to support quality patient care.
- Physician 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 GPSC 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 GPSC, that is unique to BC.
Proven model of care
There’s strong evidence that a system based on robust primary care is better for the patients, better for the physicians and other providers, and saves the system money.
- GPSC Evidence Summary: Patient medical homes
- College of Family Physicians Canada: Why patient medical homes?
- The Benefits of Relational Continuity in Primary Care (2017)
- The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization (2017)
- PMH: A broader persective
- GPSC Visioning Literature Reviews:
- $8.5M PMH funding to local divisions over three years
- Practice Characteristics Matrix
A guide that illustrates the continuum of the 12 attributes.
Downloadable PDF | Printable large poster
- PMH Assessment
An e-survey that highlights practice strengths and suggests opportunities for improvements, in relation to the 12 attributes.
- Patient Experience Tool
An e-questionnaire that collects patients' perspectives on their visits to a GP's practice.
- Strengthening Primary Care in BC (2018)
- Implementation of the Integrated System of Primary and Community Care (2017)
- Graphic: 12 attributes of a PMH in BC
- BCMJ column: Working together to create an integrated system of care
- Benefits of team-based care handout (2018)
- PMH/PCN Information Handout (2018)
- PMH/PCN Rack Card (2018)