This document outlines the vision and goals of the Patient's Medical Home (PMH) model in Canada. The PMH aims to establish family practices that serve as a patient-centered medical home, providing comprehensive and coordinated care for patients. It describes 10 goals of the PMH approach, including making every patient part of a practice with a personal family doctor, providing timely access to care, and supporting practices through governance and other stakeholders. The document also discusses insights from studies in the US and Canada on factors that can improve quality and lower costs within the PMH model.

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The
Patient’s Medical Home
A Vision for Canada:
The Patient’s Medical Home (PMH)
• Launched September 2011 on Parliament Hill
• The vision for the future of family practice in
Canada
• The hub – or home-base – for the provision and
coordination of all the health and medical services
needed by each of its patients
• Some primary care models emerging across
Canada

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Patient’s Medical Home Objectives
1. That every person in Canada will
have the opportunity to be part of a
family practice that serves as a Patient’s
Medical Home for themselves and their
families.
Patient’s Medical Home Objectives
2. Patients’ Medical Homes will produce the
best possible health outcomes for the
patients, the practice populations, and the
communities they serve.
3. Patients’ Medical Homes will reinforce
the importance of the Four Principles of
Family Medicine for both family physicians
and their patients.

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Goal 1. To be patient-centred
Goal 2. To ensure that every patient has a
personal family physician who will be the
most responsible provider for his or her
medical care.
Goal 3. To offer a broad scope of services
provided by teams or networks of providers.
Patient’s Medical Home: Goals
Goal 4. To ensure:
i) timely access to appointments; and
ii) advocacy for and coordination of timely
appointments with other health and medical
services needed outside the practice.
Goal 5. A Patients Medical Home will provide
each of its patients with a comprehensive
scope of family practice services that also
meets population and public health needs.
Patient’s Medical Home: Goals

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Goal 6. A Patient’s Medical Home will provide
continuity of care, relationships, and
information for its patients.
Goal 7. A Patient’s Medical Home will
maintain electronic medical records (EMRs)
for its patients.
Patient’s Medical Home: Goals
Patient’s Medical Home: Goals
Goal 8. Patients’ Medical Homes will serve
as ideal sites for training medical students,
family medicine residents, and those in
other health professions and for carrying
out family practice and primary care
research.
Goal 9. A Patient’s Medical Home will carry
out ongoing evaluation of the effectiveness
of its services as part of its commitment to
continuous quality improvement (CQI).

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Patient’s Medical Home: Goals
Goal 10. Patient’s Medical Homes will be
strongly supported:
i) internally, through governance and
management structures defined by each
practice and;
ii) externally, by all stakeholders, the public,
and other medical and health professions and
their organizations across Canada.
CFPC’s Patient’s Medical Home:
The Pillars (1)
• Patient-Centred
• Personal Family Doctor
• Team-Based Care
• Timely Access
• Comprehensive Care

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CFPC’s Patient’s Medical Home:
The Pillars (2)
• Continuity
• Electronic Records and Health Information
Technology
• Education, Training and Research
• System Supports
• Evaluation
What have we learned
from US PMH…….
• US/Canada differences
• To large extent, driven by CDM
imperatives
• Attributes leading to improved
clinical efficacy and cost?

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Leap (IHI, Wagner)
Learning from Effective Ambulatory
Practices
LEAP (cont’d)
LEAP Project Objectives:
• Identify up to 30 exemplar sites
• Collect data on innovations and
change processes, best practices
• Create a learning community
among exemplar sites
• Develop a toolkit for broad
dissemination

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Insights from LEAP….
• Performance is a system property
• Measure provider performance
• Focus on quality regardless of
reimbursement model
• Innovate, regardless of
reimbursement model
LEAP learnings
Factors leading to higher quality and
lower costs:
• Team Care
• Aligned reimbursement
• Population/panel management
• Planned, proactive care
• Self-management support (by all)
• Medication Management

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LEAP learnings
Factors leading to higher quality and
lower costs (cont’d):
• Care management /follow-up care
and coordination
• Cost-effective specialty input
• Staff training, IT, work flows
• Co-design, and ideally co-location
CFPC Supports
The “do I have a PMH practice” self-
assessment tool is complete. Two
guides on EMRs and the PMH are
underway as well as a guide on the
social determinants of health and the
PMH. CFPC is also completing a
best practices guide on patient-
centred care.

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CFPC Supports
Last year, Dr. Cathy Faulds
presented an inspiring story of her
move to a PMH-like practice. CFPC
worked with Dr. Faulds to produce a
<5 minute video:
English: https://www.youtube.com/watch?v=CTlMNGvZI9A
French: https://www.youtube.com/watch?v=VWR_pPD8U_8
CFPC Supports
The design of a PMH website is
underway. This website will house
PMH tools, guides and information
and will be interactive.

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CFPC Supports
CFPC is currently working with a
rural FP to produce a video on how
the PMH functions in a rural family
practice, linked through a network of
other health care providers.
CFPC Supports
CFPC has finalized a PMH one-
pager for use at meetings, ASAs,
FMF, for government officials, for FPs
and health care providers. Copies
are in English and French.

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BC Alignments…..
PMH
GP4
ME
Divisions
BC Alignments…
• Several other provinces moving
forward with pilot sites
• Emphasis on primary care,
integration, care coordination,
access
• Divisions Round Table: opening
discussion of “teams” in FFS
environment

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Patient Medical Home
Thank you, and one
pearl….
remember this is about incremental
change, and building alliances