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The patient medical home: Working together to create an integrated system of care
- 1. 15bc medical journal vol. 59 no. 1, january/february 2017 bcmj.org M oving toward an integrated system of care means cre- ating a health care system that improves support for patients— particularly vulnerable patients— through enhanced and simplified link- ages between providers. The patient medical home model is an important component in building this system. But what does this look like in practi- cal terms? The patient medical home: Working together to create an integrated system of care This article is the opinion of the General Prac- tice Services Committee and has not been peer reviewed by the BCMJ Editorial Board. What is a patient medical home? A patient medical home is a longitu- dinal GP practice in which doctors are supported to practise with the support of a team as part of a team ( Figure ), which may include non- physician health care professionals such as nurse practitioners, nurses, social workers, pharmacists, and dietitians. The patient medical home is networked with other practices, and these practices and networks are linked to additional health care ser- vices provided outside of the practice. By working within their practice and networking with other physicians and health care providers, physicians are better enabled to deliver or enhance access to a broad range of services for their patients. The overall concept of the patient medical home comes from the Cana- dian College of Family Physicians (CCFP), which describes the pillars of a patient medical home.1 The Col- lege describes the patient’s medical home as “the patient-centred fam- ily practice identified by its patients gpsc Overall goal: Patient-centred, whole-person care Figure. The 12 attributes of a patient medical home. Continued on page 16
- 2. 16 bc medical journal vol. 59 no. 1, january/february 2017 bcmj.org as the place that serves as the home base or central hub for the timely pro- vision and coordination of all their health and medical care needs.”2 The CCFP’s initiative builds a vision for the future of family practice in which every family practice across Canada delivers care that is patient-centred, encompasses patients at every stage of life, and is linked to other health services. Through this model, patients are ensured the best possible out- comes through their family physi- cian’s collaboration with a team or network of providers.2 In BC the GPSC has adapted this model and included two additional attributes, influenced by the existence of divisions of family practice. Divi- sions can enable linkages between GP practices, creating a network of care. Additionally, though representing the local community network of physi- cians, divisions are influencing the broader design of the integrated sys- tem of care in response to local health care needs identified in their commu- nities. Variations on the patient medical home model—including Ontario’s family health teams and Alberta’s primary care networks—have been implemented across North America and internationally. The patient medical home model in Ontario The patient medical home model in Ontario is realized through family health teams. Since 2005 Ontario has implemented 184 family health teams across 200 communities, which cur- rently serve over 3 million patients.3 The composition of the family health team is flexible, based on local health and community needs, and includes family physicians and a multidis- ciplinary team of other health pro- fessionals like nurse practitioners, nurses, social workers, and dieti- tians.3 Family health teams provide a wide range of services and coordinate care provided by specialists and com- munity providers.4 The patient medical home model in Alberta Alberta’s primary care networks are groups of family physicians work- ing with other health care profession- als to meet the needs of their local community—essential attributes of the primary care home model. There are 42 primary care networks in the province, consisting of approximate- ly 3800 physicians and the full-time equivalent of 1000 other health care providers such as nurses, dietitians, and pharmacists, delivering prima- ry care services to approximately 3.5 million Albertans. Primary care networks emphasize health promo- tion, disease and injury prevention, and care of patients with complex or chronic diseases. They also work to improve the coordination of primary care with hospital, long-term, and specialty care.5 The patient medical home model in BC The GPSC’s vision is to enable ac- cess to quality primary health care that effectively meets the needs of patients and populations in BC, using the BC patient medical home as the foundation for delivery, linked with a broader, integrated system of pri- mary and community care. Creating an integrated system of care involves a reorientation of some health care services—developing improved linkages between patient medical homes, networks of patient medical homes, and outside services provided by health authorities. As the GPSC works to develop and support the patient medical home model, health authorities are working to streamline the specialized services they provide, starting with services for frail older adults with complex medical issues and patients with mental health and substance use issues. Much of this work is being built on a foundation of innovations and solutions created through divisions’ work on A GP for Me—like the Mar- tin Street Outreach Clinic in Pentic- ton. The clinic, a partnership between Interior Health and the South Okana- gan Similkameen Division of Family Practice, takes a team-based approach to mental health and substance use care. Family doctors provide prima- ry care while a social worker offers patient education and facilitates engagement with local services and professionals in the community to link patients with critical supports such as housing. Other professionals provide case management, counsel- ing, diabetes education, and other ser- vices. Once patients are stabilized at the clinic, they are connected with a family physician in the community. If a community option is not available or appropriate, patients are able to receive care at the clinic on an ongo- ing basis. As of March 2016, in just under 1 year of operation, the clinic sup- ported more than 500 patients who did not previously have a family doc- tor, and the clinic social worker made more than 400 patient referrals to community services—a great exam- ple of team-based care work between family physicians, multidisciplinary partners, and health authority servic- es that supports the patient medical home model. Through the move to the patient medical home model, the GPSC’s goals are to: • Increase patient access to appropri- ate, comprehensive, quality prima- ry health care for each community. • Improve support for patients, partic- ularly vulnerable patients, through enhanced and simplified linkages between providers. • Contribute to a more effective, ef- ficient, and sustainable health care system that will increase capacity and meet future patient needs. • Retain and attract family doctors and teams working with them in gpsc Continued from page 15
- 3. 17bc medical journal vol. 59 no. 1, january/february 2017 bcmj.org healthy and vibrant work environ- ments. The GPSC is working to clear the path to care by creating smoother con- nections for family doctors—through patient medical homes—to teams of health professionals, networks, and better-coordinated specialty ser- vices in the community. By working together in new ways, the GPSC and its partners can better: • Meet the needs of patients now and into the future, so patients have timely access to continuous, coordi- nated primary and community care across practitioners and locations. • Manage the impacts of a changing workforce—resulting from retir- ing GPs and work practices of new GPs—so we can continue to deliver care effectively and keep up with patient demand for access. • Establish strong, healthy, and af- fordable health care for the future. This also supports physicians in a number of ways. Through patient medical homes, and with the support of teams and networks of health pro- fessionals and strong links to the com- munity: • Family physicians know their pa- tients are getting the right care, in the right place, at the right time. • Responsibility for patient support won’t rest on one physician’s shoul- ders. Pressures are eased, so physi- cians can achieve better work-life balance and look out for their own wellness too. • Divisions and family physicians can create healthy and vibrant work environments that will also attract new doctors. As this is a multiyear endeavor, the GPSC has committed to support- ing targeted implementation of the work in phases in order to support its partners—specifically physicians and divisions of family practice—to manage the workload. Work current- ly underway includes understanding current health needs in a communi- ty, engaging and moving toward the patient medical home model, align- ing GPSC programs and initiatives to support patient medical homes, identifying barriers and working on gpsc a provincial level to address these, and developing implementation guidelines and supporting tools and resources. For more information on the patient medical home in BC, visit www.gpscbc.ca. —Brenda Hefford, MD Executive Director, Community Practice, Quality and Integration, Doctors of BC References 1. College of Family Physicians of Canada. What is the patient’s medical home? Accessed 22 December 2016. www .cfpc.ca/What_is_PMH. 2. College of Family Physicians of Canada. A vision for Canada. Family practice: The patient’s medical home. Accessed 22 De- cember 2016. http://patientsmedical home.ca/files/uploads/PMH_A_Vision _for_Canada.pdf. 3. Ontario Ministry of Health and Long-Term Care. Family health terms. Accessed 22 December 2016. www.health.gov.on.ca/ en/pro/programs/fht/fht_understanding .aspx 4. Rosser WW, Colwill JM, Kasperski J, Wil- son L. Patient-centered medical homes in Ontario. N Engl J Med 2010;362:e7. 5. Alberta Health. Primary care networks. Accessed 22 December 2016. www .health.alberta.ca/services/primary-care -networks.html. An integrated system of care involves… developing improved linkages between patient medical homes, networks of patient medical homes, and outside services provided by health authorities.