Patient medical home: an important vehicle to enable increased access to primary care

The GPSC has set out a vision to contribute to an integrated system of care; to ensure doctors are better supported to care for patients by working more closely with other providers, teams and networks, and through seamless links to and from the community. This integration will build capacity in the system and enable better access to continuous primary care for more patients.

The GPSC's vision is to enable access to quality primary health care that effectively meets the needs of patients and populations in BC, using the patient medical home to form the foundation for care delivery within  a broader, integrated system of primary and community care.

The four goals that the GPSC is aiming to achieve are to:

  • Increase access to appropriate, comprehensive, quality primary health care for each community.
  • Improve support for patients, particularly vulnerable patients, through enhanced and simplified linkages between providers.
  • Contribute to building a more effective, efficient, and sustainable health care system in order to increase capacity and meet future patient needs.
  • Retain and attract family doctors and teams to work together in healthy and vibrant work environments.

At the heart of an integrated system is the patient medical home – a family practice made up of doctors and team members within the practice. Patient medical homes are linked together with other GPs, health professionals and teams in practice and in the community, as well as health authority and community services in broader, community-based primary care networks.

These directions are all part of the evolution of primary care, which is truly becoming the foundation of our entire health care system. We are now moving forward to build on the efforts and successes of physician leaders, divisions of family practice and partners – working with government and health authorities – in initiatives such as A GP for Me and other GPSC programs.

So why integration? In short, to create better ways for family doctors to get support for patients, and for more people to get access to care.

Patients receive excellent care when they see their family doctor, but GPs need support to meet the growing needs and complexities of our population. Doctors are working longer and harder to support more patients with complex medical needs, but are stretched thin and challenged to stay ahead of the demand. And, just as concerning, many patients do not have access to primary care at all.

GPs may have difficulty linking patients to comprehensive support and a wider range of services when needed. Physicians may feel isolated from support even in a group practice; and connecting to community and specialty services they know are out there can feel like a maze: complicated and time consuming, with long waits. Without a clear path to care, many doctors are doing it all, alone.

When faced with these kinds of pressures on the front line, work-life balance is more than just a catch phrase for GPs: it is a real concern when it comes to physicians’ health and career longevity.

Doctors need a clearer path to care so they can provide the best care possible for their patients, while achieving a healthy work-life balance. The good news is the system has been orienting in new directions. Doctors told the GPSC through the visioning consultations that they are open to new and different ways of practising, and some are exploring those directions. More team-based care providers such as nurses and social workers work directly with GP practices to support patients with complex conditions, and to simplify the process of accessing community services. While there are pockets of these models emerging in some BC communities and in rural areas, they are not yet universally available across all practices and communities.

Meanwhile, many people still can’t access continuous, coordinated primary care. Vulnerable individuals, such as those with mental health issues and the frail elderly often end up in the emergency room.    

More needs to be done to clear the path for doctors to access more networks of support so they can ensure patients get access to appropriate primary care. So, how can a system of integrated primary and community care help?

Instead of supporting complex patients in isolation, family physicians, through patient medical homes, are closely linked to networks of care including team-based support and specialty services at the practice level and in the community. Health authorities are working to make many of these services more visible, accessible and seamless, and over time, easier for providers to connect with each other.

With a clear path to care, doctors can get better support for patients with complex medical needs such as the frail elderly and those with mental health issues. Patients can more easily move between their doctor’s office and other health care providers to get comprehensive care.

GPs can feel comfort and satisfaction in the knowledge that patients are well supported with the right care, in the right place, at the right time – inside and outside of the doctor’s office and between appointments. Not all of the responsibility is on one physician’s shoulders. Time pressures can be eased for GPs, and physician wellness and work-life balance get a boost.

These are all qualities that younger doctors seek in a rewarding medical career, which have the benefit of attracting more doctors to our communities and retaining physicians already in practice. New doctors, together with efficiencies created through a supportive, integrated system of care, can build capacity to help more new patients get access to primary care.

Looking forward, the increased attention on patients with health issues and preventative care in a stronger primary care system can help relieve some critical pressures experienced by acute care and residential care systems.

As we come together to make the shift toward integrated care, we do not have to start from scratch. The groundwork has already been laid with doctors, divisions and partners, which have explored new and better ways to work together and create more unity between providers, and the efforts of health authorities to streamline services. Now, with patient medical homes as central to an integrated system, we have the opportunity to bring it all together. It is all leading to promising new directions for patients, providers, and communities across BC.