Patient Medical Homes (PMHs) and Primary Care Networks (PCNs)

What is a patient medical home (PMH)?

A patient medical home is a family physician practice where patients get the majority of their care. It builds on what GPs are already doing in their practice, and adds more supports to take it to the next level, which include:

  • Better use of EMR data (achieved through panel management) for proactive patient care and efficient use of practice resources.
  • More team support from allied health professionals and other providers.
  • Physician networks for peer and patient support.
  • Being part of a primary care network to access clinical services in the community.

The practice operates at an ideal to provide longitudinal patient care. Other primary care clinics, such as a community health centre or health authority-run clinic can also function as a PMH. Patient medical homes are the foundation of primary care networks – the broader system of services and supports in the community.

How does a PMH help patients?

Patients get better access to continuous, comprehensive, and coordinated primary care to support their full range of medical needs. Patients have a relationship with a GP who directs their care, and arranges expanded services in the community.

How does a PMH help doctors?

A PMH brings more supports into a family practice to help GPs to care for patients, especially those with complex needs like the frail elderly, and patients needing mental health care. A PMH connects GPs to broader community-based teams and services.

With the support of teams, networks and data:

  • Doctors get relief from caring for patients alone, which can help avoid burnout.
  • They can spend more time on difficult diagnoses, patient relationships and longitudinal care.
  • They can make the most of their practice resources, time, and capacity.

Why should doctors look to create a patient medical home?

A PMH frees you up to do the work you love to do, and for what brought you into the medical profession in the first place.

What is a primary care network (PCN)?

A PCN is a clinical network of providers in a geographic area. It is where patients receive expanded, comprehensive care. Patient Medical Homes are the foundation of PCNs.

PCNs include GPs in patient medical homes (PMHs), allied health care providers, health authority services and community health services. Everyone works together to provide all of the primary care services for the local population.

PCNs reorganize the way everyone works together by strengthening teamwork, communication and links. Collectively, they bring services together around GPs and patients in PMHs.

How do PCNs help patients?

Patients receive expanded, timely, comprehensive, coordinated care outside of the doctor’s office when they need it, arranged by their GP. A PCN creates capacity in a community to increase access to primary care for people without a family doctor.

How does a PCN help doctors?

As part of a primary care network, family doctors have access to a supportive network of health care providers and services outside of the practice to expand care for patients.

Family doctors get more support to do their job, including:

  • direct access to an array of clinical services
  • team-based care help for patients 
  • connections with other parts of the system
  • feedback about how their patients are doing when they are receiving care from allied health care providers or community services.

What is the difference between a PMH and PCN?

A patient medical home (PMH) is a family physician practice, or community health centre or health authority clinic. It is where patients get the majority of their care.

A primary care network (PCN) is a clinical network of primary care providers in a geographic area, including doctors in PMHs. It is where patients receive expanded, comprehensive care.

Read more about the differences.

How do PMHs and PCNs mutually support each other?

A PMH supports a practice to operate at an ideal level, which in turn creates a strong foundation for primary care networks in the community.

A PCN makes the whole community stronger, which in turn supports GPs to care for patients and create patient medical homes.

Read more about the differences.

Who is responsible for creating PMHs and PCNs?

Family doctors, their practice partners and practice teams are responsible for the creation of PMHs in family practices. GP practices are supported by the GPSC with funding, coaching and tools.

Divisions of family practice and their health authority and community partners share primary responsibility for the creation PCNs in local communities. Decisions are made through a local Collaborative Services Committee (CSC) or PCN Steering Committee. Strategic oversight is provided via a provincial collaborative table (Primary and Community Care Advisory Forum) and Interdivisional Strategic Council, and the Ministry of Health.

Are doctors already doing this?

Some are, some aren’t. The creation of PMHs and PCNs is an evolving area of work in BC.

Some doctors are using EMR data for proactive, preventative care. Others may be getting support from allied health care providers located in their practice or in the community.

In many rural areas of BC doctors already work in this way. Primary care is integrated with the community care, and doctors work closely with other doctors and health care providers as a team.

What will stay the same?

The creation of PMHs and PCNs is the next step in the evolution of primary care reform in BC.

It builds on changes that physicians have been leading for the last decade, including through A GP for Me, residential care initiatives and the GPSC fee incentives.

Some attributes of the patient medical home are what doctors are already doing: patient-centered care, commitment (attachment), coordination, contact (access), continuity and comprehensiveness of care.

The GPSC support for full service family practice with emphasis on attachment and longitudinal patient care relationships continues. Some communities and practices –particularly in rural areas– already work this way to a great extent.

What do doctors think of this work?

Physicians said through the GPSC Visioning consultation in 2015 that they are open to new and different ways of practicing so they can provide the best care possible for their patients, while achieving a healthy work-life balance. We also know that newer doctors want to practice in more flexible, team-oriented work environments.

How does a practice pay for these changes?

Targeted tools, resources and teams for practices and divisions are provided by the GPSC programs like the Practice Support Program and Doctors Technology Office. Practice-level incentive fee are available for panel management.

$250,000 has been provided for each division of family practice from GPSC to resource PCN development and change management in their communities.

Over time, the Ministry of Health will fund allied health and other providers to establish inter-professional teams.

Why is it important to assess the practice's panel when establishing PMHs and PCNs?

Doctors can use their EMR data to identify the kind of team-based support they need in their patient medical home.

They can work with other doctors and the local division to determine what kinds of supports the community needs as whole, when establishing PCNs.

Read more about panel management.

When is the work happening?

The creation of PMHs and PCNs are an emerging area of work in BC.

Divisions of family practice and health authority partners have started the work to create PCNs in some BC communities. Other communities will follow.

Transformation of the health care system will not happen overnight, but in stages, as GPs and divisions and health authority partners work out new models of care, and new ways for providers to work together.

How can GPs get involved?

The best place to start is by identifying supports that you need for your patients through the process of panel management, through which you can:

  • Use EMR data to know and plan for your patients’ needs.
  • Identify team-based supports that would help you.
  • Connect with other GPs to plan for mutual patient supports in the community.