The current global pandemic caused by the novel coronavirus has presented the international medical community with unprecedented ethical challenges. The most difficult of these has involved making decisions about access to scarce resources when demand outweighs capacity.
In Canada, it is well accepted that everyone should have an equal opportunity to access and receive medical treatment. This is possible when there are sufficient resources. But in contexts of resource scarcity, when there are insufficient resources, difficult decisions have to be made about who receives critical care (e.g., ICU beds, ventilators) by triaging patients. Triage is a process for determining which patients receive treatment and/or which level of care under what circumstances in contexts of resource scarcity. Priority-setting for resource allocation becomes more ethically complex during catastrophic times or in public health emergencies, such as today’s COVID-19 pandemic, when there is a need to manage a potential surge of patients.
Physicians from China to Italy to Spain to the United States have found themselves in the unfathomable position of having to triage their most seriously ill patients and decide which ones should have access to ventilators and which should not, and which allocation criteria should be used to make these decisions. While the Canadian Medical Association hopes that Canadian physicians will not be faced with these agonizing choices, it is our intent, through this framework, to provide them with guidance in case they do and enable them to make ethically justifiable informed decisions in the face of difficult ethical dilemmas. Invoking this framework to ground decisions about who has access to critical care and who does not should only be made as a last resort. As always, physicians should carefully document their clinical and ethical decisions and the reasoning behind them.
Generally, the CMA would spend many months in deliberations and consultations with numerous stakeholders, including patients and the public, before producing a document such as this one. The current situation, unfortunately, did not allow for such a process. We have turned instead to documents, reports and policies produced by our Italian colleagues and ethicists and physicians from Canada and around the world, as well as provincial level documents and frameworks.
The CMA is endorsing and recommending that Canadian physicians use the guidance provided by Emmanuel and colleagues in the New England Journal of Medicine article dated from March 23rd, as outlined below. We believe these recommendations represent the best current approach to this situation, produced using the highest current standard of evidence by a panel of internationally recognized experts. We also recognize that the situation is changing constantly, and these guidelines may need to be updated as required.
The CMA will continue to advocate for access to personal protective equipment, ventilators and ICU equipment and resources. We also encourage physicians to make themselves aware of any relevant provincial or local documents, and to seek advice from their regulatory body or liability protection provider. It should be noted that some provinces and indeed individual health care facilities will have their own protocols or frameworks in place. At the time of its publication, this document was broadly consistent with those protocols that we were given an opportunity to review.
The CMA recognizes that physicians may experience moral distress when making these decisions. We encourage physicians to seek peer support and practice self-care. In addition, the CMA recommends that triage teams or committees be convened where feasible in order to help separate clinical decision making from resource allocation, thereby lessening the moral burden being placed on the individual physician.
The CMA recommends that physicians receive legal protection to ensure that they can continue providing needed care to patients with confidence and support and without fear of civil or criminal liability or professional discipline. In this time of uncertainty, physicians should be reassured that their good faith efforts to provide care during such a crisis will not put them at increased medical-legal risk. Providing such reassurance is needed so that physicians have the confidence to continue to provide care to their patients.
Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important. This value reflects the importance of responsible stewardship of resources: it is difficult to justify asking health care workers and the public to take risks and make sacrifices if the promise that their efforts will save and lengthen lives is illusory. Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. There are many reasonable ways of balancing saving more lives against saving more years of life; whatever balance between lives and life-years is chosen must be applied consistently.
Limited time and information in a Covid-19 pandemic make it justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim. The latter becomes relevant only in comparing patients whose likelihood of survival is similar. Limited time and information during an emergency also counsel against incorporating patients’ future quality of life, and quality-adjusted life-years, into benefit maximization. Doing so would require time-consuming collection of information and would present ethical and legal problems. However, encouraging all patients, especially those facing the prospect of intensive care, to document in an advance care directive what future quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining interventions can be appropriate.
Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life.
Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do. Initially allocating beds and ventilators according to the value of maximizing benefits could help reduce the need for withdrawal.
Recommendation 2: Irrespective of Recommendation 1, Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses and RTs are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost. Whether health workers who need ventilators will be able to return to work is uncertain but giving them priority for ventilators recognizes their assumption of the high-risk work of saving others. Priority for critical workers must not be abused by prioritizing wealthy or famous persons or the politically powerful above first responders and medical staff — as has already happened for testing. Such abuses will undermine trust in the allocation framework.
Recommendation 3: For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. First-come, first-served is used for such resources as transplantable kidneys, where scarcity is long-standing, and patients can survive without the scarce resource. Conversely, treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities. And first-come, first-served medication or vaccine distribution would encourage crowding and even violence during a period when social distancing is paramount. Finally, first-come, first-served approaches mean that people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures, are excluded from treatment, worsening outcomes without improving fairness. In the face of time pressure and limited information, random selection is also preferable to trying to make finer-grained prognostic judgments within a group of roughly similar patients.
Recommendation 4: Prioritization guidelines should differ by intervention and should respond to changing scientific evidence. For instance, younger patients should not be prioritized for Covid-19 vaccines, which prevent disease rather than cure it, or for experimental post- or pre-exposure prophylaxis. Covid-19 outcomes have been significantly worse in older persons and those with chronic conditions. Invoking the value of maximizing saving lives justifies giving older persons priority for vaccines immediately after health care workers and first responders. If the vaccine supply is insufficient for patients in the highest risk categories — those over 60 years of age or with coexisting conditions — then equality supports using random selection, such as a lottery, for vaccine allocation. Invoking instrumental value justifies prioritizing younger patients for vaccines only if epidemiologic modeling shows that this would be the best way to reduce viral spread and the risk to others.
Epidemiologic modeling is even more relevant in setting priorities for coronavirus testing. Federal guidance currently gives priority to health care workers and older patients but reserving some tests for public health surveillance could improve knowledge about Covid-19 transmission and help researchers target other treatments to maximize benefits.
Conversely, ICU beds and ventilators are curative rather than preventive. Patients who need them face life-threatening conditions. Maximizing benefits requires consideration of prognosis — how long the patient is likely to live if treated — which may mean giving priority to younger patients and those with fewer coexisting conditions. This is consistent with the Italian guidelines that potentially assign a higher priority for intensive care access to younger patients with severe illness than to elderly patients. Determining the benefit-maximizing allocation of antivirals and other experimental treatments, which are likely to be most effective in patients who are seriously but not critically ill, will depend on scientific evidence. These treatments may produce the most benefit if preferentially allocated to patients who would fare badly on ventilation.
Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions. Their assumption of risk during their participation in research helps future patients, and they should be rewarded for that contribution. These rewards will also encourage other patients to participate in clinical trials. Research participation, however, should serve only as a tiebreaker among patients with similar prognoses.
Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions. If the Covid-19 pandemic leads to absolute scarcity, that scarcity will affect all patients, including those with heart failure, cancer, and other serious and life-threatening conditions requiring prompt medical attention. Fair allocation of resources that prioritizes the value of maximizing benefits applies across all patients who need resources. For example, a doctor with an allergy who goes into anaphylactic shock and needs life-saving intubation and ventilator support should receive priority over Covid-19 patients who are not frontline health care workers.
Approved by the CMA Board of Directors April 2020
Racism is a structural determinant of health and drives health and social inequities. The recent incidents of anti-Black violence, racism and discrimination in the US and Canada also shed light on the structural inequities and racism that exist within the medical profession and the health system.
The profession of medicine is grounded in respect for all people. This commitment recognizes that everyone has equal and inherent worth, the right to be valued and respected, and the right to be treated with dignity.
It’s critical that our medical culture – and society more broadly – upholds these values. But today, we’re reminded that there’s much more to do as a profession, and as a global community, to get us there.
Earlier this year, we launched our first-ever policy on equity and diversity in medicine Opens in a new window to help break down the many broad and systemic barriers that remain, to reduce discrimination and bias within our profession, and to create physically and psychologically safe environments for ourselves, our colleagues and our patients.
Alongside this policy comes a commitment to holding ourselves accountable to recognizing and challenging behaviours, practices and conditions that hinder equity and diversity, including racism.
Instances of racism, intolerance, exclusion, violence and discrimination have no place in medicine, and no place in our society. The Canadian Medical Association condemns racism in all its forms. Today, we stand alongside all those who have been affected by these appalling and inexcusable actions and beliefs.
Dr. Sandy Buchman
President, Canadian Medical Association
Concussions and head injuries are a common occurrence in sport and leisure activities, and frequently occur in occupational settings as well. While the majority of individuals who suffer from a concussion will recover with time, others may be at risk for serious and lasting complications. These include (1) children; (2) previous history of head injury or concussion; (3) prior mental health symptoms; and (4) missed diagnosis and management.
This aim of this advocacy and policy document is to improve safety during activity by raising awareness of concussions, and by working to improve the detection and safe management of concussions when they occur. It is not a clinical practice guideline. It should not be perceived as a plea to avoid sports or leisure activities, but rather as a call for safer sporting, leisure, and occupational practices. The documented health benefits that result from establishing an active lifestyle in youth and maintaining it throughout life cannot be overstated.
Achieving balance of safe play in sport, leisure and occupational activities while promoting greater physical activity levels for Canadians would have the effect of reducing health care costs in Canada, while promoting a healthier concussion recovery culture for all Canadians.
Therefore, to promote better concussion and head trauma awareness and prevention, as well as better management/treatment practices, the following policy recommendations for key target audiences across all levels of sport, leisure, and occupational activity are made.
Key Concussion & Head Injury Principles:
a) The detection of concussions and head injury should be a shared responsibility and any stakeholder/observer to such an injury should verbally raise their concerns that a concussion may have occurred.
i. It is important to understand that individuals with a possible concussion, or head injury, may not be able to recognize that they are suffering from a concussion;
ii. It is important to recognize that engrained within popular culture are dangerous notions (e.g., to minimize, ignore, downplay, or play through the pain, etc.) that cause individuals/observers to ignore the real, often hidden, dangers of such injuries.
b) Broadly speaking, access to the latest edition of the internationally recognized Concussion Recognition Tool (CRT) should be promoted/available to help identify the signs and symptoms of a possible concussion;
c) Any individual who sustains more than a minor head injury should be immediately removed from play, activity, or occupation, and not permitted to return on the same day3 (regardless of whether a concussion is later suspected).
i. These individuals should be the subject of observation for developing/evolving concussion symptoms or emergency warning signs (especially within the first 4 hours post-injury, but also up to 48 hours when red-flag symptoms are present).
d) Following first aid principles, where an individual displays signs of a serious head or spinal injury, that individual should lie still (not moving their head or neck) until a qualified individual has performed an evaluation; to determine whether emergency evacuation for medical assessment is necessary.
e) Any individual with a suspected concussion (especially where red-flag symptoms are present), or more severe traumatic brain injury, should be promptly evaluated by a physician to:
i. Either rule-out or confirm a diagnosis via an appropriate medical assessment; and
ii. Institute the provision of an age-appropriate follow-up care plan (including progressive return to school, work, and play protocols) if such an injury is confirmed.1
f) Ideally, a physician knowledgeable in concussion management determines when, and how, a concussed individual should progressively return to both cognitive (school or work) and physical activities.
g) Following a suspected, or diagnosed concussion, an individual should not return to play, or resume any activity associated with a heightened risk of head trauma, until cleared by a physician to do so.1
a) Where possible, encourage safe play practices in sports, and where appropriate, educate patients about the risks of head injuries (associated with high-risk behavior in sports, leisure and occupational activities).
b) Gain/maintain, through relevant continuous medical education, competencies related to the assessment, diagnosis and management of concussion according to most current clinical practice recommendations (e.g., latest edition of the CRT, SCAT, Child SCAT, Acute Concussion Evaluation Tool, etc.).
c) Be aware that clinical practice guidelines and assessment tools exist to assist in assessing and treating concussed individuals (e.g., Ontario Neurotrauma Foundation, Parachute Canada, etc.).
d) When assessing a patient with a potential concussion:
i. Rule out the presence of more severe traumatic brain and musculoskeletal injury;
ii. Assess for any previous concussion history, risk factors and newly arising complications;
iii. Educate and instruct parents, athletes and any individual that sustains a concussion about what to do, and what to expect, in the post concussive phase. (This should be based on the most current age-appropriate concussion management guidelines);4
iv. Provide individualized recommendations on how to optimally apply the progressive return-to-school, work, and play strategies with consideration for the specificities of the patient’s usual activities and responsibilities;4
v. Work to provide concussed patients timely access for medical reassessment in the event of worsening or persistent symptoms (including mental health); and
vi. In the presence of persistent or worsening symptoms (including mental health), consider what external, evidence based, concussion resources may be necessary as well as referral.
2. Medical Colleges & Faculties:
a) Promote/support medical education regarding; awareness, detection/diagnosis; and the appropriate management of concussions, throughout the continuum of medical education (undergraduate, post-graduate, and continuing medical education).
b) Support research in concussion prevention, detection, and treatment or management.
3. Athletes in Contact/Collision Sports:
a) (Prior to the commencement of the sporting season) be given age-appropriate instruction2 to understand:
i. How to identify the signs and symptoms of a possible concussion using the latest edition of the internationally recognized CRT (e.g. Concussion Recognition Tool, or Concussion Awareness Training Tool (CATT));
ii. The risks associated with concussion (including long term and mental health); especially, the risks of potentially life-threatening complications associated with continued sport participation, while presenting with signs or symptoms of a possible concussion;
iii. What to do/expect if a concussion is ever suspected (including for teammates), and the expected role of the athlete and team members;
iv. Removal and progressive returns to school, work and play policies/procedures, and the expected role of the athlete in the recovery process; and
v. How to foster a healthy sporting culture (that promotes: safe play practices; fosters concussion/injury prevention and reporting; peer-to-peer support; and combat injury stigmatization).
b) Have such instruction reinforced periodically throughout the sporting season as needed.
c) Be aware of, and seek treatment for, potentially serious mental health issues that may arise post-concussive injury.
4. Parents with Minors in Contact/Collision Sports:
a) Prior to the commencement of a sporting season, request and be open to receiving instruction2 on:
i. How to identify the signs and symptoms of a possible concussion using the latest edition of the internationally recognized CRT (e.g. Concussion Recognition Tool, or Concussion Awareness Training Tool (CATT));
ii. The risks associated with concussion; especially, the risks of potentially life-threatening complications associated with continued sport participation, while presenting with signs or symptoms of a possible concussion;
iii. What to do/expect if a concussion is ever suspected for an athlete;
iv. Removal and progressive returns to school, work and play policies/procedures, and the expected role of the parent(s) in the recovery process; and
v. How to foster a healthy sporting culture that promotes: safe play practices; fosters concussion/injury prevention and reporting; peer-to-peer support; and combats injury stigmatization.
b) Have such instruction reinforced periodically throughout the sporting season as needed.
c) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
5. Individuals Who Sustain a Head Injury Outside of Organized Sports:
a) Be aware of possible signs and symptoms of a possible concussion, and immediately withdraw from activity and seek medical assessment a possible concussion is suspected.1
i. Refer to the latest addition of the internationally recognized CRT (Concussion Recognition Tool) for further guidance on signs and symptoms.3
b) Understand the risks associated with concussion; including the risks of potentially life-threatening complications associated with repeated head injury if signs or symptoms of a possible concussion are present.
c) In the event of a diagnosis of concussion, judiciously implement the medical recommendations received regarding their gradual return to cognitive and physical activity (including the need for medical reassessment in the presence of persistent symptoms).
d) Openly communicate their recovery needs and work with any group or individual who might support them in their recovery process (e.g., employers, family members, school, etc.).
e) Be aware of, and seek treatment for, potentially serious mental health issues that may arise post-concussive injury.
6. Coaches, Trainers, Referees, & First Responders:
a) Receive certified emergency first aid training.
b) Receive periodic education (ideally annually) on national standards regarding the signs and symptoms, potential long-term consequences, appropriate steps for initial intervention, and immediate management (including: athlete removal-from-play; observation; determining when medical assessment is necessary; and progressive return to school, work and play procedures).
c) Be trained in the use of the latest edition of the internationally recognized CRT (Concussion Recognition Tool) – to detect whether an injured individual is suffering from a concussion.2
d) Be knowledgeable and responsible to ensure safety and safe play practices are applied throughout the sporting season.
e) Be responsible for fostering a healthy sporting culture (promote safe play practices, foster concussion/injury prevention and reporting, peer-to-peer support and combat injury stigmatization).
f) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
7. Licensed Health Care Providers Involved as Therapists in Sport Environments:
a) Be fully licensed in their professional field and pursue continuing professional development to maintain competencies related to concussion and head injuries.
b) Promote the implementation of properly adapted concussion management protocols (that comply with the most current clinical recommendations, based on consideration for the specificities of each sport environment and available resources).
c) Work with qualified physicians to initiate/implement tailored medically supervised concussion management protocols that define:
i. Mutual and shared health professional responsibilities to optimize the quality, and safety of patient care (within one’s scope of practice); and
ii. The optimal corridors for timely access to medical (re)assessment with due consideration for available resources.
d) Be prepared to address potentially serious mental health issues that may arise post-concussive injury.
8. Educational Institutions & Sports Organizations:
a) (Especially in the cases involving minors) implement, and keep updated, prevention strategies to include:
i. Safety standards that include safe play policies; and
ii. Mandatory safety gear/equipment (tailored to individual sport settings).
b) Mandatory concussion and head injury protocols that work to:
i. Reduce the occurrence of concussions and head injury by promoting: safe play practices; fostering concussion/injury prevention and reporting; peer-to-peer support, and combatting injury stigmatization;
ii. Ensure the prompt detection, and standardized early management of concussion and head injuries, by informing all potential stakeholders (in the preseason phase) about the nature/risks of concussion and head injury, and how any such occurrence will be dealt with should they occur;
iii. Enshrine into practice removal-from-play, and post-injury observation of athletes;
iv. Progressively reintegrate students back into symptom guided educational and physical activities based on the most current recommendations;2
v. Reintegrate injured athletes back into unrestricted training activities and sport once medical clearance has been obtained; and
vi. Foster better lines of communication for injury management/recovery between: parents, athletes, coaches, school personnel, therapists and physicians.
vii. Address potentially serious mental health issues that may arise post-concussive injury.
9. Employers (Occupational Considerations)
a) Comply with workplace safety laws and implement safety standards to reduce the incidence of head injuries in the work environment.
b) Integrate considerations for concussion and head injury in health and safety protocols that work to:
i. Reduce the occurrence of concussions and head injury by promoting: safe practices; concussion/injury prevention and reporting; peer-to-peer support, and combats injury stigmatization;
ii. Ensure prompt detection and standardized early management of concussion and head injuries by informing potential stakeholders about the nature/risks of concussion and head injury, and how occurrences will be dealt with should they occur;
iii. Enshrine into practice/ workplace culture the removal-from-work, and post-injury observation of workers;
iv. Progressively reintegrate workers back into symptom guided cognitive and physical activities based on the most current recommendations;
v. Reintegrate injured workers with a confirmed diagnosis of concussion, progressively back into work activities only once medical clearance has been obtained; and
vi. Foster better lines of communication, and support for, injury management between: employees, employers, medical professionals and insurances.
vii. Address the potentially serious mental health issues that may arise post-concussive injury.
10. Governments & Professional Regulatory Bodies:
a) Implement comprehensive public health strategies for the Canadian population to:
i. Increase awareness that concussions can be sustained in accidents, sports, leisure and occupational contexts;
ii. Inform head injuries should be taken seriously; and
iii. Explain how and why concussions should be prevented and promptly assessed by a physician where they are suspected to have occurred.
b) Define appropriate scopes of practice for all health professionals involved in the field of concussion detection, management, and treatment.
c) Work with key stakeholders to develop compensation structures to support physicians to allocate the time necessary to: (1) conduct appropriate assessments to rule out concussions, (2) provide ongoing concussion management, and (3) develop detailed medical clearance plans.
d) Work with key stakeholders to develop standardized educational tools for physicians to provide to patients with concussions.
i. Ideally this would include contextualized tools for sports teams, schools, and employers.
e) Adopt legislation or regulation for educational institutions and community-based sport associations to establish clear expectations/obligations regarding concussion awareness and management for youth in sports (e.g., Ontario’s Rowan’s law).
i. To have meaningful impact, such initiatives must also be accompanied by: implementation funding to support the development and implementation of sport specific concussion management protocols; and monitoring/compliance programs.
f) Establish a national concussion and sports injury surveillance system (with standardized metrics) to collect detailed head and sport injury related information. Thus, providing the ability to research such injuries in an ongoing and timely manner.
g) Provide research opportunities/funding on concussions. Specific examples of research areas to prioritize include:
i. Effective prevention strategies for both adults and children in a range of sport, leisure, or occupational environments;
ii. The incidence and impact of concussions in children, and how to reduce their occurrence (inside and outside of sport);
iii. Address knowledge gaps for concussion identification, management, and medical clearance for physicians not specialized in concussion care;
iv. Explore all health professionals’ participation in concussion management providing for respective: competency, expertise, interdisciplinary collaboration, and appropriate roles;
v. Evaluate how emerging point of care diagnostics and biomarker testing will be incorporated into sport, leisure and work environments;
vi. Continued development of effective, user-friendly, and age appropriate management strategies/tools for physicians regarding concussion identification, management, and medical clearances; and
vii. Develop a harmonized understanding of “concussion” and “mild traumatic brain injury” (MTBI) constructs/concepts, so that adults with concussion signs or symptoms, who do not meet the more restrictive MTBI criteria, are properly managed.
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus Statement on Concussion in Sport - the 5th International Conference on Concussion in Sport Held in Berlin. Br J Sports Med 2017, 51: 838-847.
Parachute Canada. Canadian Guideline on Concussion in Sport. 2017. Available: http://www.parachutecanada.org/injury-topics/item/canadian-guideline-on-concussion-in-sport (accessed 2018 Jul 31).
Concussion in Sport Group. Concussion Recognition Tool 5. Br J Sports Med 2017 51: 872. Available: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097508CRT5.full.pdf (accessed 2018 July 31st). (accessed 2018 Jul 31).
Ontario Neurotrauma Foundation. Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms. Health Care Professional Version. 3rd Ed, Adults (18 + years of age). Toronto: Ontario Neurotrauma Foundation; 2018. Available: http://braininjuryguidelines.org/concussion/fileadmin/media/adult-concussion-guidelines-3rd-edition.pdf (accessed 2018 Jul 31).
Concussion in Sport Group. Sport Concussion Assessment Tool – 5th Ed. Br J Sports Med 2017, 0:1-8. Available: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097508CRT5.full.pdf (accessed 2018 July 31).
Approved by the CMA Board of Directors March 2019
The evolving needs of patients and their communities
place ever-changing demands on the health care system
to maintain and improve the quality of services provided.
Changing population demographics, increasing
complexity, and new technology make for a dynamic
system. Family physicians are at the heart of the health
care system, acting as the first point of contact and a
reliable medical resource to the communities they serve,
caring for patients and supporting them throughout all
interactions with the health care system. The Patient’s
Medical Home (PMH) is a vision that emphasizes the role
of the family practice and family physicians in providing
high-quality, compassionate, and timely care.
The success of a PMH depends on collaboration and
teamwork—from the patient’s participation in their
care to interprofessional and intraprofessional care
providers working together, to policy-makers who can
offer infrastructure support and funding. PMH 2019 was
created with invaluable feedback from a broad range of
stakeholders reflective of such a joint approach. Its goal
is to make the PMH a reality for patients and providers
In 2011 the College of Family Physicians of Canada
(CFPC) released A Vision for Canada: Family Practice -
The Patient’s Medical Home.1 It outlined a vision for the
future of primary care by transforming the health care
system to better meet the needs of everyone living in
Canada. The vision outlined the 10 pillars that make
up the PMH and provided detailed recommendations
to assist family physicians and their teams, as well as
policy-makers and health care system administrators, to
implement this new model across the country.
WHY A REVISED PMH?
Since 2011 many principles of the PMH vision have been
embraced in primary care reforms. New models have
been introduced across Canada (see Progress on the
PMH to Date). To better reflect current realties, meet
the evolving needs of family physicians and their teams,
and support continued implementation of the PMH, the
CFPC has developed this revised edition of the vision.
It reflects evolving realities of primary care in Canada,
including the rapid adoption of electronic medical
records (EMRs)2,3 and a shift toward interprofessional
While progress has been made, there is still work to be done
to fully achieve the PMH vision. In 2016 almost 75 per cent
of Canadians rated the quality of care received from their
family physicians as good or excellent.4 In 2017 a CFPC
survey found that 79 per cent of respondents rate the care
they receive from their family doctor as excellent or good.5
However, at the same time 55 per cent of Canadians also
believed that the overall health care system still required
fundamental changes.4 In addition, Canada continues to
perform below the international average on certain aspects
of patient-centred care; for example, same- or next-day
access to appointments. While most Canadians (84.7 per
cent) have a regular doctor or place of care, they generally
report longer wait times for medical care than adults in
comparable countries.4 PMH 2019 addresses these concerns
and proposes solutions that can help further improve the
primary care system for all.
Although the specific components of the revised PMH have
been updated (see What is the Patient’s Medical Home?),
the core principles remain the same. PMH 2019 focuses on
providing high-quality, patient-centred, and comprehensive
care to patients and their families during their lifetime. It
embraces the critical role that family physicians and family
practices play in the health care system, reflecting the fact
that systems with strong primary health care deliver better
health outcomes, enhance efficiency, and improve quality of
care.6 PMH 2019 recognizes that a patient will not be able
to see their personal family physician at every visit, but can
rely on the PMH’s qualified team of health professionals to
provide the most appropriate care responding to patient
needs with continuous support and leadership from family
physicians. PMH 2019 highlights the central importance
of community adaptiveness and social accountability in
primary care with a new pillar. The importance of being
responsive to community needs through engagement, and
ensuring the provision of equitable, culturally safe, antioppressive
practise that seeks to assess and intervene into
social determinants of health (SDoH), is now more clearly
2 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PURPOSE OF THIS DOCUMENT
PMH 2019 outlines 10 revised pillars that make up a
PMH. Key attributes are defined and explained for each
pillar. Supporting research is provided to demonstrate
the evidence base for each attribute. This document
is intended to support family physicians currently
working in a PMH to better align their practice with
the PMH pillars, or assist those practices looking to
transition to a PMH. Furthermore, this document can
guide governments, policy-makers, other health care
professionals, and patients on how to structure a primary
health care system that is best-suited to meet the needs
Many resources for the PMH have been developed and
will continue to be available. These include practical Best
Advice guides on a range of topics and the self-assessment
tool that can help quantify a practice’s progress toward
PMH alignment. Moving forward, additional materials
that address the new themes identified in PMH 2019 and
the tools to support physicians in the transition to PMH
structures—for example the PMH Implementation Kit—
will be available at patientsmedicalhome.ca.
What is a Patient’s Medical Home?
The PMH is a family practice defined by its patients
as the place they feel most comfortable presenting
and discussing their personal and family health and
medical concerns. The PMH can be broken down into
three themes: Foundations, Functions, and Ongoing
Development (see Table 1 and Figure 1).
The three Foundation pillars are the supporting structures
that facilitate the care provided by the PMH. All three
aspects are required for the successful implementation
and sustainability of a PMH.
The Functions are areas central to the operation of a family
practice and consist of the five core PMH pillars. These
principles govern the type of care provided by the PMH
practices to ensure it is effective and efficient for meeting
the needs of the patients, families, and communities they
serve. The pillars in this section reflect the Four Principles
of Family Medicine,7 which underlines the important
place they take in the overall PMH 2019.
The pillars in Ongoing Development are essential to
advancing the PMH vision. These areas make it possible
for physicians to provide the best possible care for
patients in various settings. Applying these pillars, the
PMH will thrive through practising quality improvement
(QI) principles to achieve the results necessary to meet
the needs of their patients, their communities, and the
broader health care community, now and in the future.
The PMH is a vision to which every practice can aspire.
Many practices across Canada have already begun
transitioning to a PMH, thanks to the dedication and
leadership of family physicians and their teams across
Table 1. 10 Pillars of the revised PMH vision
1. Administration and Funding
2. Appropriate Infrastructure
3. Connected Care
4. Accessible Care
5. Community Adaptiveness and Social Accountability
6. Comprehensive Team-Based Care with Family Physician Leadership
7. Continuity of Care
8. Patient- and Family-Partnered Care
9. Measurement, Continuous Quality Improvement, and Research
10. Training, Education, and Continuing Professional Development
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 3
the country. This vision is a resource for these practices
as they engage in ongoing practice assessment and QI
initiatives. It can also assist other stakeholders, including
government planners, policy-makers, and funders to
better understand what defines an effective patientcentred
family practice. By involving patients in all stages
of the development, evaluation, and continuous quality
improvement (CQI) activities of the practice, the PMH
can contribute significantly to furthering the goals of
transformation to a patient-centred health care system.8
What the Patient’s Medical Home is Not
While it is important to understand what the PMH
aspires to be, it is also important to highlight that it is
not a one-size-fits-all solution. Solo practices in rural
or remote settings or large group practices serving
inner-city populations can align with PMH principles
by incorporating strategies that match the realities of
their unique settings. In fact, social accountability and
community adaptiveness is an important new addition
to the revised PMH vision to account for the need of
every family practice to adapt and respond to the needs
of their patients and communities. What works for one
practice will not work for all.
The PMH vision does not require that all practices be
relocated or re-engineered, or that significant financial
investments be made by physicians or other health
care professionals. Instead, system level support and
involvement is required to achieve the vision. The pillars
and attributes listed in this document are signposts along
the way to reform that aids practices on their journey.
It is important to note that this vision is not intended to
undermine or change any exciting initiatives involving
family practice currently under way across Canada
(several of which already embrace and incorporate
the medical home concept; see Progress on the PMH
to Date). Rather, it is meant to build on and strengthen
these efforts. The more that health care initiatives meet
PMH objectives, the more likely it is that the overall
goals of creating a patient-centred health care system
throughout Canada will be realized.
Figure 1. The Patient’s Medical Home
4 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PROGRESS ON THE PMH TO DATE
Since the release of the original PMH vision document,
system-level change has occurred in almost all
jurisdictions in Canada. More specifically, PMH-type
practices are gaining traction in various provinces and
currently exist in various stages of development.
The CFPC took a snapshot of PMH uptake in all provinces
in the PMH Provincial Report Card, published in early
2019.9 That report contains grades and descriptions for
progress in each province up to late 2018, which acts as
a useful gauge for where the vision stands at the time of
publication of this new edition.
In Alberta, primary care networks (PCNs)10 were
established to link groups of family physicians and other
health care professionals. Within PCNs clinicians work
together to provide care specific to community and
population health care needs. Currently, there are 42 PCNs
operating in Alberta, comprised of more than 3,700 (or 80
per cent of) family physicians, and over 1,100 other health
care practitioners. PCNs provide care to close to 3.6 million
Albertans, 80 per cent of the population in Alberta.
Primary care clinics are being asked to collect data for
Third Next Available (TNA) appointments to improve
access for Albertans.11 TNA measures the delay patients
experience in accessing their providers for a scheduled
appointment. TNA is considered a more accurate system
measure of access than the “next available” appointment,
since the next or second next available appointment may
have become available due to a cancellation or other
event that is not predictable or reliable.
The British Columbia government’s new primary care
strategy focuses on expanding access to team-based
care through PCNs.12 PCNs are in the initial stages of
adoption and when fully rolled out will provide a systemlevel
change—working to connect various providers to
improve access to, and quality of, care. They will allow
patients to access the full range of health care options,
streamline referrals, and provide better support to
family physicians, nurse practitioners, and other primary
health care providers. The General Practice Services
Committee13 (GPSC; a partnership of the provincial
government and Doctors of BC) specifically references
and builds on the PMH concept in their vision for the
future of British Columbia’s health care system.
In Manitoba, PMHs are Home Clinics and PCNs are My
Health Teams. My Health Teams bring together teams
of health care providers (physicians, nurses, nurse
practitioners, etc.) to collaborate in providing highquality
care based on community and patient needs.14 As
suggested by the name of the initiative itself, the goal
is to improve health care by developing teams of health
care professionals who will work together to address
primary health care needs of Manitobans.15 The first two
My Health Teams were established in 2014, and there are
now 15 across the province.16 The Manitoba Centre for
Health Policy did some work assessing the impact of My
In 2017 the government announced the New Brunswick
Family Plan, which placed a specific emphasis on access
to team-based care. To achieve this goal, the provincial
government and the New Brunswick Medical Society
established a voluntary program called Family Medicine
New Brunswick. In this team-based model, physicians
have their own rosters of patients, but also provide a
service to all patients of doctors on their team.17 It was
announced in 2018 that 25 family physicians will be
added to the provincial health care system to ensure
more New Brunswick residents have access to a primary
care physician and to help reduce wait times.18
Newfoundland and Labrador
In 2015 the Newfoundland and Labrador government
released Healthy People, Healthy Families, Healthy
Communities: A primary health care framework for
Newfoundland and Labrador. The strategy’s goals
include ensuring “timely access to comprehensive,
person-focused primary health care services and
supports,” and “primary health care reform should work
to establish teams of providers that facilitate access to
a range of health and social services tailored to meet
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 5
the needs of the communities they serve.”19 Both goals
align with the general PMH principles. Primary health
care teams have been introduced in St. John’s and are
planned for Corner Brook and Burin.20 Many initiatives
under way as a part of this strategy are in the early stages
of development. Continuing in the direction laid out will
move Newfoundland and Labrador closer to integrating
the PMH vision in their delivery of primary health care.
The recent creation of a single Territorial Health Authority
has enabled work on primary care improvements across
the Northwest Territories. In August 2018 the NWT Health
and Social Services Leadership Council unanimously
voted in favour of a resolution supporting redesigning
the health care system toward a team- and relationshipbased
approach, consistent with PMH values. In several
regions, contracted physicians are already assigned to
regularly visit remote communities and work closely
with local staff to provide continuity of remote support
between visits. Planning is under way for implementing
PMH-based multidisciplinary care teams in several larger
regional centres, with enhanced continuity and access to
physician and nursing staff as well as co-located mental
health support and other health care disciplines. This
work is facilitated by a territory-wide EMR and increased
use of telehealth and other modalities of virtual care.
The 2017 Strengthening the Primary Health Care
System in Nova Scotia report recommended establishing
“health homes,” consisting of interprofessional,
collaborative family practice teams. The model is based
on a population health approach that focuses on wellness
and chronic disease management/prevention and
incorporates comprehensive, team-based care. There are
approximately 50 collaborative family practice21 teams
and a number of primary care teams across Nova Scotia.
The model most aligned with the PMH framework is the
family health team (FHT).22 FHTs are comprised of family
physicians, nurse practitioners, and other health care
professionals, and provide community-centred primary care
programs and services. The 184 FHTs collectively serve over
three million enrolled Ontarians. Based on the results of a
five-year evaluation undertaken by the Conference Board
of Canada in 2014, FHTs have achieved improvements
at the organizational and service-delivery levels.23 Much
progress has also been made through patient enrolment
models. Patient enrolment, or rostering, is a process in
which patients are formally registered with a primary
care provider or team. Patient enrolment facilitates
accountability by defining the population for which the
provider is responsible. Formal patient enrolment with a
primary care physician lays the foundation for a proactive
approach to chronic disease management and preventive
care.24 Studies show that the models have achieved some
degree of success in enhancing health system efficiency
in Ontario through the reducing use of emergency
departments for non-emergent care.25
Prince Edward Island
In Prince Edward Island, primary care is provided
through five PCNs.26 Each network consists of a team
that includes family physicians, nurse practitioners,
registered nurses, diabetes educators, licensed practical
nurses, clerical staff, and in some cases dietitians and
mental health workers. They offer a broad range of
health services including diagnosis, treatment, education,
disease prevention, and screening.
The Groupes de médecine de famille27 (GMF) is the
team-based care model in Quebec most closely aligned
with the PMH. GMF ranking (obligations, financial, and
professional supports) is based on weighted patient
rostering. One GMF may serve from 6,000 to more than
30,000 patients. The resource allocation (financial and
health care professionals) depends on the weighted
patient target under which the GMF falls. In a GMF,
each doctor takes care of their own registered patients,
but all physicians in the GMF can access medical
records of all patients. GMFs provide team-based care
with physicians, nurses, social workers, and other health
care professionals working collaboratively to provide
appropriate health care based on community needs.
Saskatchewan has made investments in a Connected
Care Strategy, which focuses on a team approach to
care that includes the patient and family, and extends
from the community to the hospital and back again. It is
about connecting teams and providing seamless care for
people who have multiple, ongoing health care needs,
with a particular focus on care in the community.28
6 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing
each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred
care. The foundations are Administration and Funding (includes financial and governmental support and strong
governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources,
and electronic records and other digital supports), and Connected Care (practice integration with other care settings
enabled by health IT).
Patients as partners in health care
Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a
small but powerful change in terminology. Considering and respecting patients as partners allows health care providers
to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and
feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding
the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29
Pillar 1: Administration and Funding
Practice governance and management
Effective practice governance is essential to ensuring
an integrated process of planning, coordinating,
implementing, and evaluating.30 Every PMH should
clearly define its governance and administrative structure
and functions, and identify staff responsible for each
function. While the complexity of these systems varies
depending on the practice size, the number of members
on the health care professional team, and the needs of
the population being served, every PMH should have an
organizational plan in place that helps guide the practice
From a governance perspective, policies and procedures
should be developed and regularly reviewed and
updated, especially in larger practices. These policies
and procedures will offer guidance in areas such as
organization of clinical services, appointment and
booking systems, information management, facilities,
equipment and supplies, human resources, defining PMH
team members’ clinical and administrative/management
roles and responsibilities, budget and finances, legal
and liability issues, patient and provider safety, and
CQI. In some cases, standardized defaults for these
may be available based on the province of practice and
existing structures supporting interprofessional teams.
Structures and systems need to be in place that allow
for compensated time for providers to undertake and
actively participate in CQI activities. This needs to be
scheduled and remunerated so that it is seen as being as
important and critical as clinical time.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient government funding to cover training
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 7
Practices need staff and financial support, advocacy, governance, leadership, and management in
order to function as part of the community and deliver exceptional care.
1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in
1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and
administrative roles of all members of PMH teams.
1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be
considered to incentivize the desired approach.
1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms
that support PMH priorities, including preventive care, population health, electronic records, community-based
care, and access to medications, social services, and appropriate specialist and acute care.
8 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
costs and financial support to ensure lost income is not a
barrier (see Pillar 10: Training, Education, and Continuing
Every family practice in Canada can become a PMH
and an optimal learning environment will only be
achievable with the participation and support of all
stakeholders throughout the health care system. This
includes family physicians; other health professionals
who will play critical roles on PMH teams; federal,
provincial, and territorial governments; academic
training programs; governing bodies for physicians
and allied health care providers; and most importantly,
the people of Canada themselves, individually and in
their communities—the recipients of care provided by
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Given that
the structure, composition, and organization of each
PMH will differ based on community and population
needs, funding must be flexible. More specifically,
PMH practices will differ in terms of the staff they
require (clinical, administrative, etc.). Funding must
be available to ensure that PMH practices can
determine optimal staffing levels and needs, to best
meet community needs. The health care system must
also ensure that all health care professionals on the
PMH team have appropriate liability protection, and
that adequate resources are provided to ensure that
each PMH practice can provide an optimal setting for
teaching students and residents and for conducting
practice-based research. These characteristics
are also reflected in the Four Principles of Family
Medicine, reinforcing the centrality of family medicine
to the delivery of care.
Experience through new models of family practice,
such as patient enrolment models (PEMs) in Ontario,
suggests that blended funding models are emerging as
the preferred approach to paying family physicians.31–33
These models are best suited to incentivizing teambased,
patient-partnered care. The current fee-forservice
(FFS) model incentivizes a series of short
consultations that might be insufficient to address all
of the patient’s needs, while blended remuneration
provides for groups of physicians to work together to
provide comprehensive care through office hours and
after-hours care for their rostered patients. Capitation
allows for more in-depth consultations depending on
population need, rather than a volume-based model.
Research has also found that blended capitation models
can lead to small improvements in processes of care
(e.g., meeting preventive care quality targets)34 and can
be especially useful for supporting patients in managing
and preventing chronic diseases.35 The CFPC advocates
for governments to implement blended payment
mechanisms across the country to achieve better
health outcomes (see the Best Advice guide: Physician
Remuneration in a Patient’s Medical Home36 for more
It is important to ensure that additional practice activities
such as leadership development, QI, and teaching are
supported through dedicated funding or protected time
intended specifically for these activities and are not
seen as financially disadvantageous.
The sustainability of Canada’s health care system
depends on a foundation of strong primary care and
family practice.37 Indeed, “high-performing primary care
is widely recognized as the foundation of an effective and
efficient health care system.”38 Future funding for health
care—in particular from the federal government through
federal, provincial, and territorial agreements—must
be sustained through appropriate and well-designed
funding agreements that incentivize PMH visions of
primary care; other medical home priorities including
preventive care, population health, EMRs; communitybased
care; along with access to medications, social
services, and appropriate specialist and acute care.
For the PMH vision to be successful and a part of the
future of family practice care in Canada, we need the
commitment and support of everyone in the Canadian
health care system, including decision makers and
patients. By working with all levels of government and
with patients, we can improve the health care system so
that everyone in Canada has access to patient-centred,
comprehensive, team-based care.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 9
Pillar 2: Appropriate Infrastructure
The shift in Canada from paper-based patient records
to EMRs is reaching saturation. As delivery of care
evolves with greater integration of technology, potential
applications to improve patient care expand.39 The
proportion of family physicians using EMRs has grown
from 16 per cent in 2004 to 85 per cent in 2017.40
As it becomes ubiquitous in health care delivery,
information technology can be of great benefit in
sharing information with patients, facilitating adherence
to treatment plans and medication regimes, and
using health information technology (HIT) in new and
innovative methods of care. However, HIT also poses new
risks and can create new barriers. Providers should be
mindful of how the application about new technologies
may hinder good quality patient care.
When properly implemented, EMRs can help track data
over time, identify patients who are due for preventive
visits, better monitor patient baseline parameters (such
as vaccinations and blood pressure readings), and
improve overall quality of care in a practice.1 EMRs can
enhance the capacity of every practice to store and recall
medical information on each patient and on the practice
population as a whole. They can facilitate sharing
information needed for referrals and consultations.
The information in an electronic record can be used
for teaching, carrying out practice-based research, and
evaluating the effectiveness of the practice change as
part of a commitment to CQI.1 EMRs and HIT actively
support other pillars in the PMH vision.
In addition to storing and sharing information, the
biggest benefit of this technology is the ability to
collect data for practice performance and health
outcomes of patients served by family practices.41 The
data allow practices to measure progress through
CQI goals. Larger-scale collection allows for the
aggregation of anonymized data sets and measuring
performance beyond the practice level.41 Strict privacy
regulations ensure that patient data remain secure
and confidential. Overall, QI and research benefit
patients by guiding more appropriate and efficient
care, which forms the basis of another key pillar of
Physical space, staffing, electronic records and other digital supports, equipment, and virtual
networks facilitate the delivery of timely, accessible, and comprehensive care.
2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems.
2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes
family physicians and other health care professionals. Practices are able to select an EMR product from a list
of regionally approved vendors.
2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary
care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools;
e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research,
evaluation, and CQI.
2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable.
2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and
interaction between team members.
2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered
nurses to meet PMH goals).
2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare.
2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements
will be met by every PMH teaching site.
the PMH vision— Pillar 9: Measurement, Continuous
Quality Improvement, and Research.
As EMR use becomes common, issues shift from rollout
to optimization in the practice. Ideally, EMRs must
be adequately supported financially and use a universal
terminology to allow for standardized data management,
and be interoperable with other electronic health
records relevant to patient care.1 Training and ongoing
technical support for effective use of technology must
also be available. Digital information sources, especially
in the sensitive areas of patient information and care
planning, require a higher level of technical support
to maintain faith in their use and application across
A comprehensive, systematic analysis of peer-reviewed
and grey literature found that cost sharing or financial
sponsorship from governments is required to support the
high cost of EMR adoption and maintenance. Governments
in several European countries equip all primary care
practices with interoperable, ambulatory care-focused
electronic health records (EHRs) that allow information
to flow across settings to enhance the continuity
and coordination of care.1 Ensuring that government
supports enable adoption, maintenance and effective use,
coordination, and interoperability of electronic tools is
crucial for meaningful use of this technology.
A PMH will also use technology for alternative forms
of care. Virtual care is clinical interactions that do not
require patients and providers to be in the same room
at the same time.42 Virtual visits will be financially
compensated by provincial health plans. Consultations
may be asynchronous, where patients answer structured
clinical questions online and then receive care from a
physician at a later time (e-visits), or synchronous,
where patients interact with physicians in real time via
telephone (teleconsultations), videoconference (virtual
visits), or text.43 Virtual care increases accessibility
for those living in rural and remote areas, but also in
urban areas where some patients do not have a regular
primary care physician or cannot access their physician
for in-person appointments within a time frame that
meets their current needs.43 Virtual care can also be an
alternative solution for patients living in long-term care
facilities and/or with mobility issues.43
Strong communication between team members allows
PMH practices to function on a virtual basis when the
health care professionals are not stationed in the same
physical space. It is important to recognize when colocation
is not feasible and maintain effective information
flow in these situations, which may be especially relevant
in rural and remote areas.
Practices should ensure the electronic records they
use are set up to support collaboration and interaction
between all members of the team as much as possible,
which includes all health care providers within the PMH
as well as the patient’s circle of support. For example,
ensuring that when patients see someone other than
their most responsible provider is logged into the
system and is easy to review to maintain the continuity
of care. This becomes complex in situations where
providers are not co-located, and further system level
supports up to the level of more interoperable and
universal electronic records is a prerequisite for full
application of this principle.
Appropriate infrastructure in a PMH is not just
about technology—it includes efficient, effective, and
ergonomically well-designed reception, administration,
and clinical areas in the office. This is of significant
benefit to staff and patients alike.44 Having a shared
physical and/or virtual space where multiple team
members can meet to build relationships and trust,
and communicate with each other regarding patient
care is essential to creating a collaborative practice.
Team-based care thrives when care is intentional,
when planned and regular patient care meetings are
incorporated into usual PMH practice, and when these
steps are included in remuneration. This collaboration
ensures that patients are involved in all relevant
Satisfaction with virtual visits
A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of
high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their
10 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 11
discussions and are receiving the best care from
professionals with a comprehensive set of skills.
A family practice should be physically accessible to
patients and their families. This includes ensuring all
public areas, washrooms, and offices are wheelchair
accessible.44 An examination room should comfortably
accommodate the patient and whatever appropriate
companion, or health care professionals, who may be
in the room at the same time. Having multi-purpose
rooms also reduces or eliminates the need to wait for an
appropriate room to be available.
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Research
demonstrates that in the case of EMRs, key barriers
to adoption by family physicians include financial
and time constraints, lack of knowledgeable support
personnel, lack of interoperability with hospital and
pharmacy systems,45 as well as provincial/territorial EHR
systems. Therefore, government must assure funding
to support the PMH team in their clinical, research,
and administrative responsibilities. There must also be
support for core practice components such as EMRs,
patient-centred practice strategies such as group visits,
and electronic communications between patients and
health professionals (see Pillar 1: Administration and
Funding). EMRs should help improve the delivery of care
in community-based practices by enhancing productivity
and processes. They are not intended to reduce time
with patients, nor should they cause physician burnout
or have a negative impact on physician wellness. While
the structures supporting the PMH practices differs by
province, it is important they cover a common set of
principles enabling the base functionalities described in
this document. The system must also ensure that all health
professionals on the PMH team have appropriate liability
protection and that adequate resources are provided so
that each PMH practice can provide an optimal setting
for teaching students and residents and for conducting
practice-based research. Provider autonomy is critical
to provider wellness: as physician leadership within the
PMH is one of the key pillars, preservation of physician
autonomy, while respecting the autonomy and ensuring
the accountability of both patients and other health care
professionals, must be addressed.
Figure 2. The Patient’s Medical Neighbourhood
Pillar 3: Connected Care
Canada Health Infoway
Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal
government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative
strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada.
Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals.
Connectivity and effective communication within and
across settings of care is a crucial concept of a PMH.
This ensures that the care patients receive is coordinated
and continuous. To achieve this, each PMH should
establish, maintain, and use defined links with secondary
and tertiary care providers, including local hospitals;
other specialists and medical care clinics; public health
units; and laboratory, diagnostic imaging, physiotherapy,
mental health and addiction, rehabilitation, and other
health and social services.
Connected care is a priority for many health care
organizations in Canada. For example, the Canadian
Foundation for Healthcare Improvement (CFHI) has
established a unique program that looks at improving
care connections between providers through improved
use of technology.41 (See the Canadian Foundation for
Healthcare Improvement textbox for more information).
The Canadian Nurses Association (CNA), Canadian
Medical Association (CMA), and HEAL recognize
that giving Canadians the best health and health care
requires creating a functionally integrated health
system along the full continuum of care—a system
based on interprofessional collaborative teams that
ensure the right provider, at the right time, in the right
place, for the right care.46 Similarly, Canada Health
Infoway focuses on expanding digital health across the
system to improve quality of and access to care.
The PMH exists within the broader patient’s medical
neighbourhood (see Figure 2), with links to all other
providers in the community. It is important to maintain
connections with colleagues in health care as well as
social support organizations within the community, as
described in Pillar 5: Community Adaptiveness and
Through links within the neighbourhood, PMH practices
work with other providers to ensure timely access
for referrals/consultations and define processes for
information sharing. Establishing and maintaining
these links requires open and frequent communication
between all those involved in patient care.
12 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
Practice integration with other care settings and services, a process enabled by integrating health
3.1 A PMH is connected with the health and social services available in the community for patient referrals.
3.2 Defined links are established between the PMH and other medical specialists, and medical care services in
the local or nearest community to ensure timely referrals.
3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information
technology. It ensures the continuity of patient information received throughout the medical and social
Ideally PMH practices act as the central hub for patient
care by collecting and coordinating relevant patient
information from external care providers and patients.
This includes medical care and care accessed through
other health and social services; for example, services
received through home care programs. PMH practices
should also be able to share relevant information with
external providers where and when appropriate, while
strictly adhering to relevant privacy regulations. This
two-way flow of information ensures that all providers in
the network of care have access to the most accurate
and comprehensive information available, allowing them
“… to spend less time looking for information and more
time on what matters: treating the patient.” 49
Overall, connected care in the PMH and the health
system is enabled through HIT systems. PMH practices
continuously strive to work efficiently with other
providers in the patient’s medical neighborhood by
taking advantage of developing technologies that make
links quicker to establish and easier to maintain.
To use HIT systems for coordinated care, the following
Interoperable EMR and other health information
Real-time access to data and the ability to relay
accurate information in a timely manner
Reliable communication mechanisms between
various health and social service providers and the
Privacy for patient information
It is important to keep in mind that any patient information, generated during the provision of care,
belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act
(PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information.
Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of
EMRs50 for more information.
Canadian Foundation for Healthcare Improvement
The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative
Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with
specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait
times for accessing specialty care by enabling family physicians to more efficiently manage their patients in
primary care settings.
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14 A NEW VISION FOR CANADA Family Practice—
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The functions describe the heart of the PMH and the care provided by PMH practices. These are the key
elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community
Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership;
Continuity of Care; and Patient- and Family-Partnered Care.
COMMUNITY ADAPTIVENESS &
CARE WITH FAMILY PHYSICIAN
CONTINUITY OF CARE
PATIENT & FAMILY PARTNERED CARE
Equitable and ethical practices
The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly,
accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54
Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the
CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices
in health care and public health.55
Pillar 4: Accessible Care
A NEW VISION FOR CANADA Family Practice—
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Accessible primary care is fundamental to a highperforming
health care system and is considered by
patients52 and other health care organizations as one
of the most important characteristics of primary health
care. For care to be accessible, all patients should have
access to a family physician who acts as their most
responsible provider and is supported by a team of
qualified health professionals. Patients must be able
to access medical care and treatment when needed.
While most Canadians currently have a regular family
doctor,4 it is important that the goal be for everyone in
Canada to have access to their own family physicians.
Accessible care is about more than just quick access to
appointments. It does include timely access principles,
but also advanced access, virtual access, and teambased
approaches to care that ensure patients can be
seen by the most appropriate provider when they need
to be seen.
Because visits occur for different reasons it is not useful
to define appropriate wait times for each type of visit
unlike in other areas of health care, such as surgery.
Therefore, the focus in family practice should be on
enhancing access to ensure patients can access care
when they feel it is necessary. This is not to say that
family physicians in a PMH must be on call 24/7/365,
but that methods for patients to access care through
the design of practice operations and scheduling
should be given more attention. On the other hand,
as patients are offered more choice (e.g., by phone or
e-communication), they should also expect practices
to establish realistic parameters for what is reasonable.
Practices should communicate clearly about what kind of
provider availability and response time is reasonable to
expect depending on access method and availability of
resources. Obtaining this understanding from a practice’s
patients and striving to meet these expectations is a
By adopting advanced and timely access, virtual access, and team-based approaches, accessible
care ensures that patients can be seen quickly.
4.1 A PMH ensures patients have access to medical advice, and information on available care options 24
hours a day, 7 days a week, 365 days a year.
4.2 Every patient is registered with a PMH.
4.3 PMH practices offer scheduling options that ensure timely access to appropriate care.
4.4 When the patient’s personal family physician is unavailable, appointments are made with another
physician, nurse, or other qualified health professional member of the PMH team.
4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking
4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and
safe, high-quality care.
A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services
from other health care providers seen as a key for improving patient access.59
Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment
and also consults another provider in the interim), improves health outcomes, leads to better patient and provider
satisfaction, and reduces emergency visits.56–58
16 A NEW VISION FOR CANADA Family Practice—
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good way to maintain the patient-centred focus of the
practice as described in Pillar 1: Administration and
Funding. Significant shifts in providing alternative access
must be supported by funding bodies.
Same-day scheduling has been introduced in many
PMH practices to better accommodate patient needs.
Frequently referred to as doing “today’s work today,”
advanced access offers the vast majority of patients the
opportunity to book their appointments on the day they
call regardless of the reason for the visit.60 Read more
about same day scheduling in the Best Advice guide:
Timely Access to Appointments in Family Practice.61
Whenever possible, patients should have clear reasons
for the appointment at the time of booking. This ensures
that adequate time is planned for each patient visit. If
the need to address multiple problems arises, the
problems can be triaged on the spot by one of the team
and arrangements made to have these concerns dealt
with in a timely manner either during the same visit or at
It is not always possible for patients to book appointments
with their most responsible family physician. To ensure
continuity, appointments can be made with other
physicians or health care professionals in the team. The
decision about who provides care in these cases is based
on the patient’s needs, the availability of team members,
and the scope of practice for each team member. In these
cases, any relevant information from the appointment
is communicated to the most responsible provider and
taken into account in the long-term care of the patient.
PMH practices can further meet patients’ needs through
extended office hours, in which the responsibilities for
coverage and care are shared by family physicians in one
or more practices, as well as by increased involvement of
other team members. PMH practices also provide their
patients with email, after-hours telephone, and virtual
services to guide them to the right place at the right
time for the care they need. Appropriately directing
patients to the next available appointment, or to a
hospital or another emergency service, is critical to the
effective management and sustainability of our health
care system.62,63 A PMH can help ensure that patients
are aware of where they can go to access care and
health information 24 hours a day, 365 days a year by
providing this information to patients in person or via
other systems (website, voice mail messages, etc.).
In alignment with Pillar 9: Measurement, Continuous
Quality Improvement, and Research, PMH practices offer
opportunities for patients to provide feedback on the
accessibility of the practice. Specifically, patients should
have the opportunity to evaluate and provide input for the
appointment booking system. Mechanisms and supports
need to be in place to ensure that practices and governing
bodies can review and respond to feedback appropriately
and communicate this back to patients.
Determining the optimal panel size for each PMH practice
is critical to ensuring accessible and safe, high-quality
care.64 Establishing and incorporating recommendations
from the PMH vision may enable practices to consider
increasing their panel size. Actual panel size will vary
depending on the number of physicians and other team
members in the practice, the practice’s obligations and
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Social accountability refers to the family physicians’
obligation to meet the needs of Canada’s
communities.66 For health care to be socially
accountable, it must be accessible by everyone and
responsive to the needs of patients, communities, and
the broader population.4 This obligation is embedded
in the Family Medicine Professional Profile and the
Four Principles of Family Medicine, highlighting that
family physicians are community-adaptive, responding
to the needs of their patients and communities.
These principles of family medicine align well with
the principles of social accountability. Family practice
is relationship-based care that embraces all issues
of need and endures over time and place of care. A
generalist keeps the whole in mind while attending
to the individual parts, the system in mind when
fixing individual problems, and the end in mind
when commencing the journey. Tools exist to help
family physicians and other health care providers
enhance their skills and training regarding social
accountability and cultural safety through many
professional organizations and cross-Canada
resource hubs like the National Collaborating
Centre of Determinants of Health67 and the National
Collaborating Centre on Aboriginal Health,68 as
PMH practices are aware of how the SDoH influence the
health of patients and communities. Family physicians are
often the best-situated primary care professionals to act on
Pillar 5: Community Adaptiveness and Social Accountability
A PMH is accountable to its community, and meets their needs through interventions at the patient,
practice, community, and policy level.
5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing,
immigration status) as relevant for the individual, community, and policy levels.
5.2 Panel size will consider the community’s needs and patients’ safety.
5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to
meet unique community needs.
Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using
the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in
Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe,
seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender,
race, class, sexual orientation, gender identity, ability, etc.
commitment to teaching and research, and the needs
of the population being served (see Pillar 5: Community
Adaptiveness and Social Accountability). When deciding
panel size, each practice must determine how accepting
more patients into the practice might impact the
current population, the sustainability of the workload for
physicians and other members of the PMH team, and
the consequences of panel size on experience of care.
Refer to the Best Advice guide: Panel Size for more
issues that affect patients’ SDoH. Advocating for patients
and the health care system overall is a natural part of a
PMH structure. Advocacy can occur at three levels:69
Micro: In the immediate clinical environment, daily
work with individual patients and predicated on
the principles of caring and compassion
Meso: In the local community, including the
patient’s cultural community, the local community
of medical providers, and the larger civic
community, in which health professionals are
citizens as well as practitioners
Macro: In the humanitarian realm, where physicians
are concerned with the welfare of their entire
patient population and seek to improve human
welfare through healthy public policy (such as
reducing income inequality, supporting equitable
and progressive taxation, and expanding the
social safety net)
The principles of advocacy in family practice are found
in the CanMEDS–Family Medicine 201769 competency
framework, under the Health Advocate role. The
Best Advice guide: Social Determinants of Health70
describes how family physicians in the PMH can make
advocacy a practical part of their practice.
Poverty is a significant risk factor for chronic disease,
mental illness, and other health conditions. Low income
and other SDoH also present significant barriers to
accessing care.71 To meet the needs of these patients,
practices may need to extend hours, be more flexible
and responsive, and spend additional time helping
patients navigate and access necessary care. PMH
practices consider other specific community needs when
determining appropriate panel size. Demographics and
health status of the patient population can influence the
length and frequency of appointments needed, thereby
impacting a physician’s caseload.65 For example, a PMH
in a community with high rates of chronic conditions
may need to reduce the panel size to provide timely and
high-quality care, given that patients require more care
time and resources. Similarly, a patient’s social situation
may impact the time a family physician spends with
them. Family physicians and team members may need to
use a translator at clinical appointments, and may need
to provide written resources in alternative languages,
all factors affecting the time required to provide care.
Enabling PMH practices to adjust panel size based on
community needs requires governments to establish
blended payment mechanisms. These remuneration
systems ensure family physicians are adequately
compensated, and are not financially disincentivized from
spending the necessary time with patients (see Pillar 1:
Administration and Funding, for more information).
Social accountability and cultural competency
Part of the response to being more socially accountable with care offered to the community resides within each
and every health professional. While courses on cultural competency are now a standard part of medical education,
physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases
that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is
a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the
satisfaction of being an effective healer—of ourselves, our patients and our societies.
Importance of social accountability
Social accountability is a key value for health care organizations and professionals. For example, the Royal College
of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of
Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability
within their organizations and the work they do.
18 A NEW VISION FOR CANADA Family Practice—
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Family physicians and their PMH teams are situated
at the nexus of individual and population health, and
can engage with their patients in addressing health
promotion and disease prevention in creative ways. From
accompanying individual patients through teachable
moments (e.g., the smoker with pneumonia ready to quit)
to influencing civic policy to address homelessness, the
stories entrusted to family physicians in daily practice
are powerful tools for healthy change. These teams
are also key providers in many important public health
areas, including illness and injury prevention; health
promotion; screening and managing chronic diseases;
immunizations; and health surveillance. PMH practices
prioritize delivering evidence-based care for illness and
injury prevention and health promotion, reinforcing
them at each patient visit and other counselling
opportunities. PMHs and local or regional public health
units should cultivate and maintain strong links with one
another. Health care professionals who are part of PMH
teams may take on advisory, educational, supportive, or
active roles in public health initiatives, in many different
occupational, educational, or recreational settings
throughout the community. An effective public health
system should be inextricably linked to communitybased
family physicians and PMHs, recognizing and
supporting them as essential to the achievement of the
broader population and public health goals.
While PMHs focus primarily on the care of individuals
and their families, it is important for team members to
understand and address the health challenges facing
their practice populations and the larger community.
These broader challenges represent upstream factors
(SDoH) that have greater impact on the health of patients
than do the efforts of individual physicians. However,
the relationships embedded in individual and collective
practices can be central to engaging patients and
citizens in building more just and healthier communities
and societies. For example, with the help of HIT, details
about the needs of populations can be more easily
accessed through extraction from practice EMRs, or
participation in programs such as the Canadian Primary
Care Sentinel Surveillance Network (CPCSSN).73 The
CPCSSN networks collect health information from
EMRs of participating primary care providers, extract
anonymous data, and share information on chronic
conditions with governments, health care providers,
and researchers to help inform meaningful systems
and practice change. Programs like the CPCSSN allow
practices to better understand the needs of their
communities and implement specific health promotion
and prevention programs that can contribute to the
population’s overall well-being. Initiatives like this also
ensure the avoidance of data duplication, and recognise
that practices do not need (or have the resources) to
collect data on their own. However, these data are just
a part of caring—the heart of generalism is keeping the
whole in mind while attending to its parts, whether it is
at the level of the whole patient, the whole family, or the
To meet the needs of their diverse panel of patients, family
physicians and other team members in the PMH work to
provide anti-oppressive and culturally-safe care, seeking
to mitigate experiences of discrimination faced by many
patients based on their SDoH. This requires understanding
how historical and current injustices have impacted the
well-being of certain populations, and working to ensure a
safe and welcoming practice environment by focusing on
the principles of caring and compassion.
Sociodemographic data benefits
The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed
about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated
into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data
will also be used for planning and evaluating the FHT’s programs.74
A NEW VISION FOR CANADA Family Practice—
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Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership
Primary care practice teams
Many allied health professional organizations have prioritized the importance of working together in a team to
provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the
CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of
Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes
implementation strategies for creating a primary practice team, and general descriptions of roles found in a
20 A NEW VISION FOR CANADA Family Practice—
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A broad range of services is offered by an interprofessional team. The patient does not always see
their family physician but interactions with all team members are communicated efficiently within a
PMH. The team might not be co-located but the patient is always seen by a professional with relevant
skills who can connect with a physician (ideally the patient’s own personal physician) as necessary.
6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel
of registered patients.
6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or
network, collaborating with the patient’s personal family physician to provide timely access to a broad range
of primary care and consulting services.
6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged
and supported as part of each PMH.
6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team
members may be co-located or may function as part of virtual networks.
6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the
roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers,
physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed.
6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing
ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal
medical home team.
6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles,
professional scopes of practice, and personally acquired competencies. Their roles providing both episodic
and ongoing care support and complement—but do not replace—those of the family physician.
Team-based care is a core function of the PMH. Building
a team with a diverse mix of professional backgrounds
creates an opportunity to redefine what is considered
optimal, based on the needs of the practice and the
community it serves. A high-performing team is essential
to delivering more comprehensive, coordinated, and
effective care centred on the patient’s needs. While
different circumstances call for aspects of patient care
to be provided by different health professionals, it is
important to ensure that family physician expertise is
available to all team members through consultation.
To practice effectively in an interprofessional health care
team, there must be a clear understanding of each member’s
unique contributions, including educational background,
scopes of practice and knowledge, and areas of excellence
and limitations.76 Practices that draw on the expertise of a
variety of team members are more likely to provide patients
with the care they need and respond to community needs.77
Relationships across all dynamics within a practice,
whether between a patient and family physician or
between a patient and other members of the team,
should be encouraged and supported in the PMH.
Establishing these relationships develops trust and
confidence, and works toward the ultimate goal of
achieving better health outcomes. While it should be
left to each practice to determine who does what (within
the boundaries of professional scopes of practice), the
most responsible provider for the medical care for each
patient in the practice should be the patient’s personal
Family physicians with enhanced skills and family
physicians with focused practices play an important role in
collaborating with the patient’s personal family physician
and team to provide timely access to a range of primary
care and consulting services. They supplement their
core skills and experience with additional expertise in a
particular field, while remaining committed to their core
generalist principles.78 These doctors can draw extensively
on their generalist training and approach to disease
management and patient-centred care, enabling them to
work collaboratively at different levels of care, including
with other specialists, to meet patient needs.79 These
clinicians also serve as a resource for other physicians in
their local health system by enhancing care delivery and
learning and teaching opportunities. The Best Advice
guide: Communities of Practice in the Patient’s Medical
Home80 provides more information about intraprofessional
collaboration between family physicians.
Shared care strategies provide patients with timely access
to consultations with other specialists or family physicians
with enhanced skills at scheduled times in the family
practice office setting. The consultant might assess several
patients per visit, at which time a plan for ongoing care
can be developed and agreed to by the family physician,
consultant, other team members, and the patient.
There is no one-size-fits-all model when determining
what mix of health care professionals is right. Team
composition depends on the professional competencies,
skills, and experiences needed to address the health
needs of the patient population.81 These needs vary,
depending on the communities’ defining characteristics;
Additional members of practice teams
Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice
can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices
can also host other health care professionals, such as those employed with a regional health authority, to provide
care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other
health care professionals often carry the overhead costs associated with these practitioners working on site,
and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1:
Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly
funded and have access to the right infrastructure (physical and governance) to support the initiatives described
in this vision.
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22 A NEW VISION FOR CANADA Family Practice—
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for example, geography, culture, language, demographics,
disease prevalence. Family physicians are encouraged
to identify the gaps in health care provision in the local
practice environment and work with other health care
providers to meet those needs as much as possible. Data
from EMRs—as well as input from patients, community
members, and stakeholders—should inform team
planning. Factors to consider include:
Identified community health care needs
Hours available for patient access
Hours available for each physician to work
Roles and number of non-physician providers
Overlapping or variations of similar competencies can
result in ambiguous expectations of what a defined role is
within a practice. When teams are planned and developed,
roles should be clearly outlined. This is best done at the
local practice level relative to community needs and
resources. This approach considers changes over the
course of a health care professional’s career, including
skills development, achievement of certifications, and
professional interests.82 It is important to include time
for team members to become comfortable in their role,
at the outset of team-based care and with any changes
to the team. It is also important to recognize that
these arrangements are flexible and subject to change,
provided the team engages in discussion and reaches
consensus on needed adjustments.
Team members might be in the same office or in the same
building, but this is not necessary. For smaller and more
remote practices, or larger urban centres where proximate
physical space may be a barrier, some connections may
be arranged with peers in other sites. Applying HIT
judiciously allows for virtual referrals and consultations.
Virtual links between PMH practices and other specialists,
hospitals, diagnostic services, etc., can be enhanced with
more formal agreements and commitments to provide
timely access to care and services.
By providing patients with a comprehensive array of
services that best meet their needs, team-based care
can lead to better access, higher patient and provider
satisfaction, and greater resource efficiency.61,77,83
Although there are presently many systems in place that
support the creation of health care teams, practices can
also create a successful team on their own. To ensure
team success, providers must have a clear understanding
of the different role responsibilities and ensure that
there are tools available to engage open dialogue and
communication. Teams within the PMH are supported by
a model that is flexible and adaptable to each situation.
The skills that family physicians acquire during their
training (as described in the CanMEDS-FM framework)
make them well suited to provide leadership within
interprofessional teams. As an important part of a PMH,
teams are central to the concept of patient-centred care
that is comprehensive, timely, and continuous.
A NEW VISION FOR CANADA Family Practice—
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Pillar 7: Continuity of Care
Continuity of care is defined by consistency over time
related to where, how, and by whom each person’s medical
care needs are addressed throughout the course of their
life.84 With strong links to comprehensive team-based
care (see Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership), continuity of care
is essential to any practice trying to deliver care truly
centred on the needs of the patient. Continuity of care
is rooted in a long-term patient-physician partnership
in which the physician knows the patient’s history from
experience and can integrate new information and
decisions from a whole-person perspective efficiently
without extensive investigation or record review.84 From
the patient’s perspective, this includes understanding
each person’s life journey and the context this brings
to current health status, and the trust they have in their
provider that is built over time.
Past studies show that when the same physician attends
to a person over time, for both minor and more serious
health problems, the patient-physician relationship is
strengthened and understanding grows—an essential
element of effective primary health care.85 The personal
physician offers their medical knowledge and expertise
for a more complete understanding of the patient as
a person, including the patient’s medical history and
their broader social context, such as personal, family,
social, and work histories (see Pillar 5: Community
Adaptiveness and Social Accountability). In this model,
patients, their families and/or personal caregivers, and
all health care providers in the PMH team are partners in
care, working together to achieve the patient’s goals and
engaging in shared decision making. Understanding the
patient’s needs, hopes, and fears, and their patterns of
response to illness, medications, and other treatments,
deepens the physician’s ability to respond to larger
trends, not just the medical issue presented at any given
appointment. Continuity of care can ideally support the
health and well-being of patients actively and in their daily
lives without focusing only on care when they are ill. The
strong physician-patient relationship developed over time
allows them to maintain good health and prevent illness
and injury, as the physician uses their deep knowledge
of their patient to work with teams of qualified health
professionals to best support the patient’s well-being.
Family physicians in the PMH, acting as the most
responsible provider, can provide continuous care
over the patient’s lifespan and develop strong
relationships with patients. Research demonstrates
that one of the most significant contributors to better
population health is continuity of care.86,87 It found
that those who see the same primary care physician
continuously over time have better health outcomes,
reduced emergency department use, and reductions
in hospitalizations versus those who receive care
from many different physicians. A Canadian study
found that after controlling for demographics and
health status, continuity of care was a predictor
of decreased hospitalization for ambulatory caresensitive
conditions (such as such as COPD, asthma,
diabetes, and heart failure) and decreased emergency
department visits for a wide range of family practicesensitive
conditions.85 Overall “the more physicians
patients see, the greater the likelihood of adverse
effects; seeking care from multiple physicians in
Patients live healthier, fuller lives when they receive care from a responsible provider who journeys
with them and knows how their health changes over time.
7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby
ensuring continuous care across the patient’s lifespan.
7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the
family practice office, hospitals, long-term care and other community-based institutions, and the patient’s
7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical
services their patients receive throughout the medical community.
the presence of high burdens of morbidity will be
associated with a greater likelihood of adverse side
effects.”86 It has been reported that a regular and
consistent source of care is associated with better
access to preventive care services, regardless of the
patient’s financial status.
Continuity of care also requires continuity in medical
settings, information, and relationships. Having most
medical services provided or coordinated in the same
place by one’s personal family physician and team
has been shown to result in better health outcomes.88
As described in Pillar 3: Connected Care, when care
must be provided in different settings or by different
health professionals (i.e., the medical neighbourhood),
continuity can still be preserved if the PMH plays a
coordination role and communicates effectively with
other providers. The PMH liaises with external care
providers to coordinate all aspects of care provided
to patients based on their needs. This includes but is
not limited to submitting and following up on referrals
to specialized services, coordinating home care, and
working with patients before and after discharge from
hospitals or other critical care centres.
In addition to this coordination role, the PMH acts as
a hub by sharing, collecting, storing, and acting as a
steward for all relevant patient information. This ensures
that the family physician, as the most responsible provider,
has a complete overview of the patient’s history. A record
of care provided for each patient should be available in
each medical record (preferably through an EMR) and
available to all appropriate care providers (see Pillar 2:
Appropriate Infrastructure for more information about
EMRs). Knowing that medical information from all sources
(i.e., providers inside and outside the PMH) is consolidated
in one location (physical or virtual) increases the comfort
and trust of patients regarding their care.
Continuity for patient health
Research demonstrates that continuity of care is a key contributor to overall population health. Patients
with a regular family physician experience better health outcomes and fewer hospitalizations as compared
to those without.69
24 A NEW VISION FOR CANADA Family Practice—
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Pillar 8: Patient- and Family-Partnered Care
External factors for patient health care
Patient- and family-partnered care is considered a key value to stakeholders across the health care system. In 2011,
the CMA and the CNA released a set of principles to guide the transformation of Canada’s health care system.91
Patient-centred care is listed as the first principle, and as a key component of improving the overall health care
experience.91 Similarly, in 2016 Patients Canada called on all levels of government to ensure that patients are at
the centre of any new health accords and future health care reform.92
* Family caregivers include relatives, partners, friends, neighbours, and other community members.
Patient-centred care is at the core of the PMH. Dr. Ian
McWhinney—often considered the “father of family
medicine”—describes patient-centred care as the
provider “enter[ing] the patient’s world, to see the illness
through the patient’s eyes … [It] is closely congruent
with and responsive to patients’ wants, needs and
preferences.”89 In this model, patients, their families and/
or personal caregivers, and all health care providers in
the PMH team are partners in care, working together
to achieve the patient’s goals and engaging in shareddecision
making. Care should always reflect the patient’s
feelings and expectations and meet their individual
needs. Refer to the Best Advice guide: Patient-Centred
Care in a Patient’s Medical Home90 for more information.
Family caregivers* play an important role in the PMH.
They help patients manage and cope with illness and can
assist physicians by acting as a reliable source of health
information and collaborating to develop and enact
treatment plans.93 The level and type of engagement
from family caregivers should always be determined
by the patient. Physicians “should routinely assess the
patient’s wishes regarding the nature and degree of
caregiver participation in the clinical encounter and
strive to provide the patient’s desired level of privacy.”94
They should revisit this conversation regularly and make
changes based on patient desires. PMH practices focus
on providing patient-centred care and ensuring that
family caregivers are included.
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Family practices respond to the unique needs of patients and their families within the context of
8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’
feelings, preferences, and expectations.
8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making
8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as
agreed upon with their care team.
8.4 Self-managed care is encouraged and supported as part of the care plans for each patient.
8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g.,
telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH.
8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys)
are part of ongoing planning and evaluation.
As part of their commitment to patient-centred care, PMH
practices facilitate and support patient self-management.
Self-management interventions such as support for
decision making, self-monitoring, and psychological and
social support, have been demonstrated to improve
health outcomes.95 PMH team members should always
consider recommendations for care from the patient’s
perspective. They should work collaboratively with
patients and their caregivers to develop realistic action
plans and teach problem-solving and coping. This is
particularly important for those with chronic conditions,
who must work in partnership with their physician
and health care team to manage their condition over
time. (Refer to the Best Advice guide: Chronic Care
Management in a Patient’s Medical Home96 for more
information). The goal of self-managed care should be
to build the patient’s and caregiver’s confidence in their
ability to deal effectively with illnesses, improve health
outcomes, and foster overall well-being.
To facilitate patient- and family-partnered care, a range
of user-friendly options for accessing information
and care beyond the traditional office visit should
be available to patients when appropriate. These
include email, telehealth, virtual care, mobile health
units, e-consults, home visits, same-day scheduling,
group visits, self-care strategies, patient education,
and treatment sessions offered in community settings.
Providing a range of options allows patients to access
the type of care they prefer based on individual needs.
Patients also need to be informed about how they can
access information and resources available to them; for
example, resources such as Prevention in Hand (PiH).97
Allowing patients to access to their medical records
can improve patient-provider communication and
increase patient satisfaction.98,99 The specific information
accessible to patients should be discussed and agreed
upon by the patient and their care team. Patient
education about accessing and interpreting the available
information is necessary. Facilitating this type of access
requires each PMH to have an EMR system that allows
external users to access information securely (see Pillar
2: Appropriate Infrastructure).
Patient surveys and opportunities for patients to
participate in planning and evaluating the effectiveness
of the practice’s services should be encouraged; practices
must be willing respond and adapt to patient feedback.
To strengthen a patient-centred approach, practices may
consider developing patients’ advisory councils or other
formalized feedback mechanisms (e.g., using patient surveys)
as part of their CQI processes (see Pillar 9: Measurement,
Continuous Quality Improvement, and Research).
The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can
improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an
environment of learning and seeks to encourage health literacy among its patients through its various programs.
The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to
patients to remove financial barriers to access.
26 A NEW VISION FOR CANADA Family Practice—
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Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to
Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional
28 A NEW VISION FOR CANADA Family Practice—
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Continuous quality improvement
CQI is an important value among health organizations such as the CFHI.100
Pillar 9: Measurement, Continuous Quality
Improvement, and Research
CQI is an essential characteristic of the PMH vision.
It encourages health care teams to make practical
improvements to their practice, while monitoring the
effectiveness of their services, the health outcomes
and safety of their patients, and the satisfaction of
both patients and the health professionals on the team.
Every PMH is committed to establishing a CQI program
that will improve patient safety, and enhance efficiency
and quality of the services provided to patients. As
part of CQI activities, a structured approach is used
to evaluate current practice processes and improve
systems and to achieve desired outcomes.
To engage in CQI, the PMH team must identify the
desired outcomes and determine appropriate evaluation
strategies. Once the process and the desired outcome
are defined with patients, the CQI activity will track
performance through data collection and comparison
with the baseline. Performance measures can be
captured through structured observation, patient and
staff surveys (see Pillar 8: Patient- and Family-
Partnered Care), the PMH self-assessment tool,
and the practice’s EMR (see Pillar 1: Administration
and Funding and Pillar 3: Connected Care). The
indicators selected should be appropriate to each
practice and community setting, be meaningful to
the patients and community, and the CQI process
could be introduced as a practice’s self-monitoring
improvement program or as an assessment carried
out by an external group.
In some jurisdictions, funding is tied to achieving
performance targets, including those that provide
evidence for the delivery of more cost-effective care
and better health outcomes.101 Some provinces in
Canada have begun to link financial incentives to clinical
outcomes and targets that have been achieved (“pay
for performance” models).102 Although there may be
some benefits derived by this approach, there can also
be risks if funding incentives and resource supports
become overly focused on patients with certain medical
problems or on those who have greater potential to reach
prescribed targets, while at the same time care is being
delayed or denied for others.101,103 Future development
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Family practices strive for progress through performance measurement and CQI. Patient safety is always
a focus, and new ideas are brought to the fore through patient engagement in QI and research activities.
9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and
the services they provide for patient and provider satisfaction.
9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH.
9.3 All members of the health professional team (both clinical and support teams), as well as trainees and
patients, will participate in the CQI activity carried out in each PMH.
9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate
in research carried out in their practice settings.
9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the
effectiveness of care and services.
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of financial incentive models should consider these
unintended consequences that might impair the ability
of practices to provide good quality patient care to their
The objectives that define a PMH could be used to develop
the indicators for CQI initiatives in family practices
across Canada. These criteria could be augmented
by indicators recommended by organizations such as
Accreditation Canada, Health Quality Ontario, Health
Standards Organization, and the Patient-Centered
Medical Home model in the United States. The CFPC is
committed to collaborating with these groups to further
develop the CQI process for PMHs and family practices.
Consult the CFPC’s Practice Improvement Initiative
(Pii)104 for a list of available resources.
CQI is a team activity and should involve all members
of the PMH team as well as patients and trainees. This
will ensure buy-in from the team, allow for patient
engagement and participation, and provide trainees with
valuable learning opportunities.105 PMHs are committed
to using the results of CQI initiatives to make tangible
changes in their practice to improve operations, services,
Time and effort invested into participation in CQI
activities should be recognized as valuable and not be
disincentivized through existing remuneration models.
Dedicated time and capacity to perform these activities
should be built into the practice operational principles.
On a larger scale, PMHs function as ideal sites for
community-based research focused on patient health
outcomes and the effectiveness of care and services.
The PMH team should be encouraged and supported
to participate in research activities. They should also
advocate for medical students, residents, and trainees
to take part in these projects. In Canada, the Canadian
Primary Healthcare Research Network (CPHRN) and
the commitment of the Canadian Institutes for Health
Research’s (CIHR’s) Strategy for Patient-Oriented
Research (SPOR) are vitally important.106 The focus on
supporting patient-oriented research carried out in
community primary care settings is consistent with the
priorities of the PMH.
Competitions for research grants such as those
announced by SPOR should be strongly encouraged
and supported. PMHs are ideal laboratories for
studies that embrace the principles of comparative
effectiveness research (CER) and the priorities
defined by the CPHRN and CIHR’s SPOR project.
They provide excellent settings for multi-site research
initiatives, including projects like those currently
undertaken by the CPCSSN—a nationwide network of
family physicians conducting surveillance of various
30 A NEW VISION FOR CANADA Family Practice—
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Pillar 10: Training, Education, and
Continuing Professional Development
PMH practices serve as training sites for medical
students, family medicine residents, and those training
to become nurses and other health care professionals.107
They create space for modelling and teaching practices
focused on the essential roles of family physicians and
interprofessional teams as part of the continuum of a
health care system. One of the goals of family medicine
residency training is for residents to learn to function
as a member of an interdisciplinary team, caring for
patients in a variety of settings including family practice
offices, hospitals, long-term care and other communitybased
institutions, and patients’ residences.70,108
A PMH also models making research and QI initiatives
a standard feature of a family practice. Professional
development and opportunities to participate in these
activities should be available and supported within PMH
practices through resources, guidance, and specifically
Family medicine training is increasingly focused on
achieving and maintaining competencies defined by the
CFPC’s Triple C Family Medicine Curriculum.109 Triple C
includes five domains of care: care of patients across the
life cycle; care across clinical settings (urban and rural);
a defined spectrum of clinical responsibilities; care of
marginalized/disadvantaged patients and populations;
and a defined list of core procedures. Triple C also
incorporates the Four Principles of Family Medicine and
the CanMEDS-FM Roles.
PMHs allow family medicine students and residents to
achieve the competencies of the Triple C curriculum and
to learn how to incorporate the Four Principles of Family
Medicine, the Family Medicine Professional Profile, and
the CanMEDS-FM roles into their professional lives.
Learners gain experience with patient-partnered care,
teams/networks, EMRs, timely access to appointments,
comprehensive continuing care, management of
undifferentiated and complex problems, coordination of
care, practice-based research, and CQI—essential elements
of family practice in Canada. Furthermore, PMH practices
serve as optimal sites for trainees in other medical specialties
and health professions to gain valuable experience working
in interprofessional teams and providing high quality,
patient-centred care. Medical schools and residency
programs should encourage learners to conduct some of
their training within PMH practices.
Emphasis on training and education ensures that the knowledge and expertise of family physicians can
be shared with the broader health care community, and also over time by creating learning organizations
where both students and fully practising family physicians can stay at the forefront of best practice.
10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations
for the experiential training of their students and residents.
10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks,
EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated
and complex problems, coordination of care, practice-based research, and CQI.
10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to
achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the
Four Principles of Family Medicine, and the CanMEDS-FM Roles.
10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development
(CPD) to meet the needs of their patients and their communities both individually and as a team.
10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community.
Practising family physicians must engage in CPD to keep
current on medical and health care developments and
to ensure their expertise reflects the changing needs of
their patients, communities, and learners.
Mainpro+® (Maintenance of Proficiency) is the CFPC’s
program designed to support and promote family
physicians’ CPD across all CanMEDS-FM Roles and
CPD refers to physicians’ professional obligation to
engage in learning activities that address their own
identified needs and the needs of their patients;
enhance knowledge, skills, and competencies across all
dimensions of professional practice; and continuously
improve their performance and health care outcomes
within their scope of practice.110 Three foundational
principles for CPD in Canada have been recently
Socially responsive to the needs of patients and
Informed by scientific evidence and practicebased
Designed to achieve improvement in physician
practice and patient outcomes
CPD is inclusive of learning across all CanMEDS-FM
Roles and competencies, including clinical expertise,
teaching and education, research and scholarship, and
in practice-based QI.
PMH practices support their physicians, and all other staff
members, to engage in CPD activities throughout their
careers by creating a learning culture in the organization.
This includes providing protected time for learning and
team-based learning, and access to practice data both
to discern patient/community need and practice gaps
to inform CPD choices and to evaluate the impact of
learning on patient care. This learning culture and the
will to be constantly improving quality and access to
care is essential to ensuring that the PMH continues to
support high performing care teams.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient funding by governments to cover
costs of training and financial support to ensure lost
income and practice capacity do not prevent this.
Physicians in the PMH share their knowledge with
colleagues in the broader health care community and
with other health care professionals in the team by
participating in education, training, and QI activities
in collaboration with the pentagram partners.† This
is particularly relevant for family physicians who are
focused on a particular area of practice (possibly
holding a Certificate of Added Competence) and are
able to share their extended expertise with others. This
can happen either informally or through more official
channels. For example, physicians may participate in
activities organized by the CFPC or provincial Chapters
(e.g., Family Medicine Forum, provincial family medicine
annual scientific assemblies), or lend their expertise to
interprofessional working groups addressing specific
topics in health care. Family physicians should be
encouraged to engage in these types of events to share
their knowledge and skills for the betterment of the
overall health system.
Continuing professional development
CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA,
and CNA emphasize the value and importance of continuing education for health care professionals to improve
† Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education
administrators; university; community; health professionals—physicians and teams
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32 A NEW VISION FOR CANADA Family Practice—
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The revised PMH vision of a high-functioning primary
care system responds to the rapidly evolving health
system and the changing needs of Canadians. The pillars
and attributes described in this document can guide
practices at various stages in the transition to a PMH,
and many characteristics are found in other foundational
documents of family medicine such as the Family
Medicine Professional Profile111 and the Four Principles
of Family Medicine. Supporting resources, such as the
PMH Implementation Kit, are available to help those
new to the transition overcome barriers to change.
Although the core components of the PMH remain the
same for all practices, each practice will implement the
recommendations according to their unique needs.
The PMH is focused on enhancing patient-centredness
in the health care system through collaboration, access,
continuity, and social accountability. It is intended to
build on the long-standing historical contribution of
family physicians and primary care to the health and wellbeing
of Canadians, as well as on the emerging models
of family practice and primary care that have been
introduced across the country. Importantly, this vision
provides goals and recommendations that can serve as
indicators. It enables patients, family physicians, other
care health professionals, researchers, health planners,
and policy-makers evaluate the effectiveness of any and
all models of family practice throughout Canada.
Those family practices that meet the goals and
recommendations described in this vision will have
become PMHs, but the concept is ever evolving. As family
physicians commit to making change in their practices,
the CFPC commits to supporting developments in the
PMH by creating and promoting new resources, which
will be available through the PMH website. The CFPC
will also play an important advocacy role to ensure that
the necessary supports are in place to reach the goals of
a PMH. Every family practice across Canada should be
supported and encouraged by the public, governments,
and other health care stakeholders (the pentagram
partners) to achieve this objective. Doing so will ensure
that every person in Canada is able to access the best
possible primary care for themselves and their loved ones.
A NEW VISION FOR CANADA Family Practice—
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1. College of Family Physicians of Canada. A Vision for Canada: Family Practice
- The Patient’s Medical Home. Mississauga, ON: College of Family Physicians
of Canada; 2011. Available from: www.cfpc.ca/uploadedFiles/Resources/
Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 2019 Jan 21.
2. National Physician Survey. 2014 National Physician Survey website. http://
nationalphysiciansurvey.ca/surveys/2014-survey/. Accessed 2019 Jan 22.
3. Canadian Medical Association. CMA Workforce Survey 2017 website. http://
cma.andornot.com/en/surveydata/default.aspx. Accessed 2019 Jan 22.
4. Canadian Institute for Health Information. How Canada Compares: Results
from the Commonwealth Fund’s 2016 International Health Policy Survey of
Adults in 11 Countries. Ottawa, ON: Canadian Institute for Health Information;
2017. Available from: www.cihi.ca/sites/default/files/document/text-alternativeversion-
2016-cmwf-en-web.pdf. Accessed 2019 Jan 22.
5. Ipsos Public Affairs. The College of Family Physicians of Canada: Family
Medicine in Canada Report. Toronto, ON: Ipsos; 2017.
6. World Health Organization. Primary Health Care website. www.who.int/
primary-health/en/. Accessed 2019 Jan 22.
7. College of Family Physicians of Canada. Four Principles of Family Medicine
website. www.cfpc.ca/Principles/. Accessed 2019 January.
8. Canadian Medical Association. Health Care Transformation in Canada:
Change that works. Care that lasts. Ottawa, ON: Canadian Medical
Association; 2018. Available from: http://policybase.cma.ca/dbtw-wpd/
PolicyPDF/PD10-05.PDF. Accessed 2019 Jan 22.
9. College of Family Physicians of Canada. The Patient’s Medical Home
Provincial Report Card—February 2019. Mississauga, ON: College of Family
Physicians of Canada; 2019. Available from: https://patientsmedicalhome.ca/
files/uploads/PMH_ReportCard_2018.pdf. Accessed 2019 February.
10. Alberta Health. Primary Care Networks website. www.health.alberta.ca/
services/primary-care-networks.html. Accessed 2018 August 16.
11. Access Improvement Measures (AIM) Alberta. Third Next Available Appointments
appointments-2/. Accessed 2019 Jan 22.
12. Office of the Premier, Ministry of Health. B.C. government’s primary healthcare
strategy focuses on faster, team-based care [news release]. Victoria, BC:
Government of British Columbia; 2018.
13. General Practice Services Committee. What We Do: Patient Medical Homes
Accessed 2018 Aug 22.
14. Government of Manitoba. Frequently Asked Questions about My Health
Teams website. www.gov.mb.ca/health/primarycare/myhts/faq.html#manitoba.
Accessed 2018 Aug 15.
15. Chateau D, Katz A, Metge C, Taylor C, McDougall C, McCulloch S. Describing
Patient Populations for the My Health Team Initiative. Winnipeg, MB: Manitoba
Centre for Health Policy; 2017. Available from: http://mchp-appserv.cpe.
umanitoba.ca/reference//hiusers_Report_web.pdf. Accessed 2019 Jan 22.
16. Government of Manitoba. Budget Paper F: Reducing Poverty and Promoting
Community Involvement. Winnipeg, MB: Government of Manitoba; 2018.
Available from: www.gov.mb.ca/finance/budget18/papers/F_Reducing_
Proverty_r.pdf. Accessed 2019 Jan 22.
17. Government of New Brunswick. New model for family medicine aims to
improve physician access [news release]. Fredericton, NB: Government of
New Brunswick; 2017. Available from: www2.gnb.ca/content/gnb/en/news/
news_release.2017.06.0849.html. Accessed 2019 Jan 22.
18. Health, Office of the Premier. Twenty-five new doctors to be added to New
Brunswick’s health-care system to reduce wait times [news release]. Fredericton,
NB: Government of New Brunswick; 2018. Available from: www2.gnb.ca/
content/gnb/en/news/news_release.2018.02.0140.html. Accessed 2019 Jan 22.
19. Government of Newfoundland and Labrador. Healthy People, Healthy
Families, Healthy Communities: A Primary Health Care Framework for
Newfoundland and Labrador 2015-2025. St. John’s, NL: Government of
Newfoundland and Labrador; 2015. Available from: www.health.gov.nl.ca/health/
publications/PHC_Framework_update_Nov26.pdf. Accessed 2018 November.
20. Health and Community Services. Supporting Health Communities: Primary
Health Care Team has Success at the Gathering Place [news release]. St. John’s,
NL: Government of Newfoundland and Labrador; 2016. Available from: www.
releases.gov.nl.ca/releases/2016/health/1124n01.aspx. Accessed 2018 Nov.
21. Nova Scotia Health Authority. Collaborative Family Practice Teams website. www.
nshealth.ca/collaborative-family-practice-teams. Accessed 2019 January.
22. Government of Ontario. Family Health Teams website. www.health.gov.on.ca/
en/pro/programs/fht/. Accessed 2018 August 16.
23. Conference Board of Canada. Final Report: An External Evaluation of the Family
Health Team (FHT) Initiative. Ottawa, ON: The Conference Board of Canada;
2014. Available from: www.conferenceboard.ca/e-library/abstract.aspx?did=6711.
Accessed 2019 Jan 22.
24. Kralj B, Kantarevic J, OMA Economics Department. Primary care model
enrolment and hospital length of stay in Ontario: patient rostering associated
with reduced length of stay, significant health system savings. Ontario
Medical Review. Sept 2012, 16-19. Available from: www.oma.org/wp-content/
uploads/sept2012_primary_care_model.pdf. Accessed 2019 Jan 22.
25. Tiagi R, Chechulin Y. The Effect of Rostering with a Patient Enrolment Model
on Emergency Department Utilization. Healthcare Policy. 2014;9(4):105-121.
Available from: www.longwoods.com/content/23809//the-effect-of-rosteringwith-
Accessed 2019 Jan 22.
26. Health PEI. Health Centres Offer Primary Care [news release]. Charlottetown,
PE: Government of Prince Edward Island; 2015. Available from: www.
care. Accessed 2019 Jan 22.
27. Gouvernement du Québec. Groupe de médecine de famille (GMF), groupe
de médecine de famille universitaire (GMF-U) et super-clinique website. www.
u-et-super-clinique/. Accessed 2019 January.
28. Government of Saskatchewan. Fact Sheet: Connected Care [news release].
Regina, SK: Government of Saskatchewan; 2018.
29. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N, Clavel N. Patients as
partners: a qualitative study of patients’ engagement in their health care.
PLoS One. 2015;10(4):e0122499.
30. Pointer DD, Orlikoff JE. Board Work: Governing Health Care Organizations.
1st ed. San Francisco, CA: Jossey-Bass; 1999.
31. Canadian Foundation for Healthcare Improvement. Mythbusters: Most
Physicians Prefer Fee-for-Services Payments. Ottawa, ON: Canadian
Foundation for Healthcare Improvement; 2010. Available from: www.cfhi-fcass.
Accessed 2019 Jan 22.
32. Blomqvist A, Busby C. How to Pay Family Doctors: Why “Pay per Patient” is
Better than Fee for Service. Toronto, ON: C.D Howe Institute; 2012. Available
mixed/Commentary_365.pdf. Accessed 2019 Jan 22.
33. Holden M, Madore O. Remuneration of Primary Care Physicians (PRB 01-35E).
Ottawa, ON: Library of Parliament, Parliamentary Research Branch; 2002.
Available from: http://publications.gc.ca/collections/Collection-R/LoPBdP/
PRB-e/PRB0135-e.pdf. Accessed 2019 Jan 22.
34. Carter R, Riverin B, Levesque JF, Gariepy G, Quesnel-Vallee A. The impact of
primary care reform on health system performance in Canada: a systematic
review. BMC Health Serv Res. 2016;16:324.
35. Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician
payment reform and team-based care for chronic disease management and
prevention. CMAJ. 2015;187(17):E494-502.
36. College of Family Physicians of Canada. Best Advice guide: Physician
Remuneration in a Patient’s Medical Home. Mississauga, ON:
34 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
College of Family Physicians of Canada; 2016. Available from: https://
remuneration-patients-medical-home/. Accessed 2019 Jan 22.
37. Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada:
systems in motion. Milbank Q. 2011;89(2): 256-288.
38. Aggarwal M, Hutchison B. Toward a Primary Care Strategy for Canada.
Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2012.
Available from: www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy-
EN.sflb.ashx. Accessed 2019 Jan 22.
39. PricewaterhouseCoopers. Canada Health Infoway: The emerging benefits
of electronic medical record use in community-based care. Toronto, ON:
PricewaterhouseCoopers; 2013. Available from: www.pwc.com/ca/en/healthcare/
2013-06-en.pdf. Accessed 2018 Jul 3.
40. Canada Health Infoway. Use of Electronic Medical Records among Canadian
Physicians, 2017 Update. Toronto, ON: Canada Health Infoway; 2017.
41. College of Family Physicians of Canada. Supporting access to data in
electronic medical records for quality improvement and research [position
statement]. Mississauga, ON: College of Family Physicians of Canada; 2017.
Available from: www.cfpc.ca/uploadedFiles/Health_Policy/CFPC_Policy_
Supporting-access-data-electronic-medical-records-EN.pdf. Accessed 2019
42. Jamieson T, Wallace R, Armstrong K, Agarwal P, Griffin B, Wong I, et al. Virtual
Care: A Framework for a Patient-Centric System. Toronto, ON: Women’s
College Hospital Institute for Health Systems Solutions and Virtual Care;
2015. Available from: www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_
VirtualHealthSymposium.pdf. Accessed 2019 Jan 22.
43. McGrail KM, Ahuja MA, Leaver CA. Virtual Visits and Patient-Centered Care:
Results of a Patient Survey and Observational Study. J Med Internet Res.
44. Canadian Medical Association. Managing your Practice website. www.cma.ca/
managing-your-practice. Accessed 2019 Jan 22.
45. Chang F, Gupta N. Progress in electronic medical record adoption in Canada.
Can Fam Physician. 2015;61(12):1076-1084.
46. Canadian Nurses Association, Canadian Medical Association, Health Action
Lobby. Integration: A New Direction for Canadian Health Care—A Report
on the Health Provider Summit Process. Ottawa, ON: Canadian Nurses
Association; 2013. Available from: www.cna-aiic.ca/~/media/cna/files/en/cna_
2019 Jan 22.
47. Canada Health Infoway website. www.infoway-inforoute.ca/en/. Accessed
2019 Jan 22.
48. Canadian Foundation for Healthcare Improvement. Connected Medicine website.
www.cfhi-fcass.ca/WhatWeDo/connected-medicine. Accessed 2018 Aug 15.
49. Rajakulendra N, Macintosh E, Salah H. Transforming Health: Toward
decentralized and connected care. Toronto, ON: MaRS Discovery District;
2014. Available from: www.marsdd.com/wp-content/uploads/2014/09/Sep15-
MaRS-Whitepapers-SmartHealth.pdf. Accessed 2019 Jan 22.
50. College of Family Physicians of Canada. Best Advice guide: Advanced and
Meaningful Use of EMRs. Mississauga, ON: College of Family Physicians of
Canada; 2018. Available from: https://patientsmedicalhome.ca/resources/
Accessed 2019 Jan 22.
51. Ontario Primary Care Council. Position Statement: Care Co-ordination in
Primary Care. Toronto, ON: Ontario Primary Care Council; 2015. Available
pdf. Accessed 2019 Jan 22.
52. Wong ST, Watson DE, Young E, Regan S. What do people think is important
about primary healthcare? Healthcare Policy. 2008; 3(3):89-104.
53. Canadian Medical Association. CMA Position Statement: Ensuring Equitable
Access to Care: Strategies for Government, Health System Planners and
the Medical Profession. Ottawa, ON: Canadian Medical Association;
2014. Available from: www.cma.ca/sites/default/files/2018-11/PD14-04-e.pdf.
Accessed 2019 Jan 22.
54. Canadian Nurses Association. Position Statement: Primary Health Care.
Ottawa, ON: Canadian Nurses Association; 2015. Available from: www.cna-aiic.
pdf. Accessed 2019 Jan 22.
55. Canadian Nurses Association. Social Justice … a means to an end, an end in
itself; 2nd edition. Ottawa, ON: Canadian Nurses Association; 2010. Available
pdf. Accessed 2019 Jan 22.
56. Barry DW, Melhado TV, Chacko KM, Lee RS, Steiner J, Kutner JS. Patient
and physician perceptions of timely access to care. J Gen Intern Med.
57. Glass DP, Kanter M, Jacobsen SJ, Minardi PM. The impact of improving access to
primary care. J Eval Clin Pract. 2017;23(6):1451-1458.
58. Hudec JC, MacDougall S, Rankin E. Advanced access appointments: effects
on family physician satisfaction, physicians’ office income, and emergency
department use. Can Fam Phys. 2010;56(10):e361-e367.
59. Stalker CA. How have physicians and patients at New Vision Family Health
Team experienced the shift to a family health team model? Final Report.
60. Murray M, Tantau C. Same-day appointments: exploding the access paradigm.
Fam Pract Manag. 2000;7(8):45-50.
61. College of Family Physicians of Canada. Best Advice guide: Timely Access
to Appointments in Family Practice. Mississauga, ON: College of Family
Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/
2019 Jan 22.
62. Lemire F. First contact: what does it mean for family practice in 2017? Can
Fam Phys. 2017;63(3):256.
63. Williams DL. Balancing rationalities: gatekeeping in health care.
J Med Ethics. 2001;27(1):25-29.
64. Murray M, Davies M, Boushon B. Panel size: How many patients can one
doctor manage? Fam Pract Manag. 2007;14(4):44-51.
65. College of Family Physicians of Canada. Best Advice guide: Panel Size.
Mississauga, ON: College of Family Physicians of Canada; 2012. Available
guide-panel-size/. Accessed 2019 Jan 22.
66. Buchman S, Woollard R, Meili R, Goel R. Practising social accountability. Can
Fam Phys. 2016; 62(1):15-18.
67. National Collaborating Centre of Determinants of Health website. www.nccdh.
ca/. Accessed 2019 Jan 22.
68. National Collaborating Centre on Aboriginal Health website. www.nccahccnsa.
ca/en/. Accessed 2019 Jan 22.
69. College of Family Physicians of Canada. CanMEDS–Family Medicine
2017: A competency framework for family physicians across the continuum.
Mississauga, ON: College of Family Physicians of Canada; 2017. Available
Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Accessed 2019 Jan
70. College of Family Physicians of Canada. Best Advice guide: Social
Determinants of Health. Mississauga, ON: College of Family Physicians of
Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/bestadvice-
guides/best-advice-guide-social-determinants-health/. Accessed 2019
71. Lightman E, Mitchell A, Wilson B. Poverty is making us sick: A comprehensive
survey of income and health in Canada. Toronto, ON: The Wellesley Institute;
2008. Available from: www.wellesleyinstitute.com/wp-content/uploads/2011/11/
povertyismakingussick.pdf. Accessed 2019 Jan 18.
72. White AA 3rd, Logghe HJ, Goodenough DA, Barnes LL, Hallward A, Allen
IM, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in
Medicine. J Racial Ethn Health Disparities. 2018;5(1):34-49.
73. Canadian Primary Care Sentinel Surveillance Network website. http://cpcssn.
ca/. Accessed 2019 Jan 22.
74. Pinto AD, Bloch G. Framework for building primary care capacity to address
the social determinants of health. Can Fam Phys. 2017;63(11):e476-482.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 35
75. College of Family Physicians of Canada. Best Advice guide: Team-Based Care
in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians
of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/
Accessed 2019 Jan 22.
76. Grant R, Finocchio L, Pew Health Professions Commission, California
Primary Care Consortium. Interdisciplinary collaborative teams in primary
care: a model curriculum and resource guide. San Francisco, CA: Pew Health
Professions Commission; 1995.
77. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, et al.
Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16-
0002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
78. Department of Health. Part 3: The accreditation of GPs and Pharmacists with
Special Interests, In: Implementing care closer to home: Convenient quality
care for patients. London, UK: Department of Health; 2007. Available from:
of_care_p3_accreditation.pdf. Accessed 2019 Jan 22.
79. Department of Health. Part 1: Introduction and overview, In: Implementing
care closer to home: Convenient quality care for patients. London, UK:
Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/
Accessed 2019 Jan 22.
80. College of Family Physicians of Canada. Best Advice guide: Communities of
Practice in the Patient’s Medical Home. Mississauga, ON: College of Family
Physicians of Canada; 2016. Available from: https://patientsmedicalhome.
Accessed 2019 Jan 22.
81. Dinh T. Improving Primary Health Care Through Collaboration: Briefing 2—
Barriers to Successful Interprofessional Teams. Ottawa, ON: The Conference
Board of Canada; 2012. Available from: www.conferenceboard.ca/e-library/
abstract.aspx?did=5181&AspxAutoDetectCookieSupport=1. Accessed 2019 Jan 22.
82. Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al.
Optimizing Scopes of Practice: New Models for a New Health Care System.
Ottawa, ON: Canadian Academy of Health Sciences; 2014.
83. Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, et al.
Generating hypotheses about care needs of high utilizers: lessons from
patient interviews. Popul Health Manag. 2013;16(Suppl1):S26-33.
84. American Academy of Family Physicians. Definition of Continuity of Care website.
www.aafp.org/about/policies/all/definition-care.html. Accessed 2018 July 25.
85. Canadian Institute for Health Information. Continuity of Care With Family
Medicine Physicians: Why It Matters. Ottawa, ON: Canadian Institute for Health
Information; 2015. Available from: https://secure.cihi.ca/free_products/UPC_
ReportFINAL_EN.pdf. Accessed 2019 Jan 22.
86. Starfield B, Chang HY, Lemke KW, Weiner JP. Ambulatory specialist use by
nonhospitalized patients in us health plans: correlates and consequences. J
Ambul Care Manage. 2009;32(3):216-25.
87. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of
care with doctors-a matter of life and death? A systematic review of continuity
of care and mortality. BMJ Open. 2018;8(6):e021161.
88. Starfield B, Shi L. The medical home, access to care, and insurance: a review
of evidence. Pediatrics. 2004;113(Supplement 4):1495.
89. McWhinney I. The Need for a Transformed Clinical Method. In:
Communicating with Medical Patients. London, UK: Sage; 1989:25.
90. College of Family Physicians of Canada. Best Advice guide: Patient-Centred
Care in a Patient’s Medical Home. Mississauga, ON: College of Family
Physicians of Canada; 2014. Available from: https://patientsmedicalhome.
Accessed 2019 Jan 22.
91. Canadian Medical Association, Canadian Nurses Association. Principles to
Guide Health Care Transformation in Canada. Ottawa, ON: Canadian Medical
92. Patients Canada. Why we need a Health Accord with Patients at the Centre
[news release]. Toronto, ON: Patients Canada; 2016. Available from: https://
centre/. Accessed 2019 Jan 22.
93. Omole FS, Sow CM, Fresh E, Babalola D, Strothers H. Interacting with
patients’ family members during the office visit. Am Fam Physician. 2011; 84(7):
94. Mitnick S, Leffler C, Hood VL; American College of Physicians Ethics,
Professionalism and Human Rights Committee. Family caregivers, patients
and physicians: ethical guidance to optimize relationships. J Gen Intern Med.
95. Panagioti M, Richardson G, Small N, Murray E, Rogers A, Kennedy A, et al.
Self-management support interventions to reduce health care utilisation
without compromising outcomes: a systematic review and meta-analysis. BMC
Health Serv Res. 2014;14:356.
96. College of Family Physicians of Canada. Best Advice guide: Chronic Care
Management in a Patient’s Medical Home. Mississauga, ON: College of Family
Physicians of Canada; 2016. Available from: https://patientsmedicalhome.ca/
medical-home/. Accessed 2019 Jan 22.
97. Prevention in Hand website. www.preventioninhand.com.
Accessed 2019 Jan 22.
98. Kruse CS, Argueta DA, Lopez L, Nair A. Patient and provider attitudes
toward the use of patient portals for the management of chronic disease: a
systematic review. J Med Internet Res. 2015;17(2):e40.
99. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality
outcomes and its implications to meaningful use: a systematic review. J Med
Internet Res. 2015;17(2):e44.
100. Health Council of Canada. Which way to quality? Key perspectives on
quality improvement in Canadian health care systems. Toronto, ON: Health
Council of Canada; 2013. Available from: https://healthcouncilcanada.ca/files/
QIReport_ENG_FA.pdf. Accessed 2019 Jan 22.
101. Mattison CA, Wilson MC. Rapid Synthesis: Examining the Effects of Valuebased
Physician Payment Models. Hamilton, ON: McMaster Health Forum;
2017. Available from: www.mcmasterforum.org/docs/default-source/productdocuments/
models.pdf?sfvrsn=2. Accessed 2019 Jan 22. \
102. Kaczorowski J, Hearps SJ, Lohfeld L, Goeree R, Donald F, Burgess K, et al.
Effect of provider and patient reminders, deployment of nurse practitioners,
and financial incentives on cervical and breast cancer screening rates. Can
Fam Phys. 2013; 59(6): e282-9.
103. Hutchison B. Pay for performance in primary care: proceed with caution,
pitfalls ahead. Healthc Policy. 2008; 4(1): 10-15.
104. College of Family Physicians of Canada. The Practice Improvement Initiative
(Pii) website. www.cfpc.ca/pii/. Accessed 2019 Jan 22.
105. Ontario College of Family Physicians. Advancing Practice Improvement
in Primary Care – Final Report. Toronto, ON: Ontario College of Family
Physicians; 2015. Available from: https://ocfp.on.ca/docs/default-source/
primary_care.pdf?sfvrsn=d793f489_4. Accessed 2019 Jan 22.
106. Canadian Institutes of Health Research. Strategy for Patient-Oriented
Research website. www.cihr-irsc.gc.ca/e/41204.html. Accessed 2019 Jan 22.
107. Hasley PB, Simak D, Cohen E, Buranosky R. Training residents to work in a
patient-centered medical home: What are the outcomes? J Grad Med Educ.
2016; 8(2): 226-231.
108. College of Family Physicians of Canada. Specific Standards for Family
Medicine Residency Programs – The Red Book. Mississauga, ON: College of
Family Physicians of Canada; 2016.
109. College of Family Physicians of Canada. Triple C Competency Based
Curriculum website. www.cfpc.ca/Triple_C/. Accessed 2019 Jan 22.
110. Filipe HP, Silva ED, Stulting AA, Golnik KC. Continuing professional
development: Best practices. Middle East Afr J Ophthalmol. 2014; 21(2): 134-141.
111. College of Family Physicians of Canada. Family Medicine Professional Profile
website. www.cfpc.ca/fmprofile/. Accessed 2019 Jan 22.
Antimicrobials (which include antibiotics) are a precious public resource and an essential tool for fighting infections in both humans and animals. Their importance to human medical, nutritional and economic security cannot be understated. Yet globally, antimicrobials are losing their effectiveness more quickly than new such drugs, treatments and therapies are being identified and introduced to market.1 Over time, this dynamic has eroded the human antimicrobial arsenal, placing the lives and futures of an unacceptable number of people at risk.
Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria, viruses, fungi and parasites come into contact with antimicrobial drugs, such as antibiotics, antivirals, antifungals, antimalarials and anthelmintics, and undergo changes. The drugs are rendered ineffective and cannot eradicate infections from the body.
AMR is an international challenge that threatens to reverse over a century of progress in public health, health care and human development attributable to antimicrobial use. Indeed, the effects of AMR are already being felt across Canada’s health care system. Currently, Canada’s dedicated investment in solutions to militate against encroaching AMR in the AMR and antimicrobial stewardship (AMS) fields (both federally and provincially/territorially) can only be viewed as wholly inadequate to address the scope of the problem and the risks it poses for the health of Canadians.
Therefore, to: (1) promote awareness of AMR; (2) incentivize investment in AMR mitigation strategies; and (3) support the mobilization of an effective suite of more clinically effective management/treatment practices and policies, the following target audience recommendations are offered.a
a All the policy recommendations made in this document are not meant to be interpreted as clinical practice guidelines. Any individual who suspects they may have an infection should promptly consult a physician.
Key AMR principle — the “One Health” approach
a) The complexity of AMR underscores the need for coordinated action known as the “One Health” approach. The term implies integrated strategies that span the human, animal/agricultural and environmental sectors. Thus, cooperation across a wide variety of stakeholders is necessary to address the collective nature of AMR. These stakeholders include governments, health professionals, private and public partners, and the public at large.
b) The One Health approach will require attention and investment in the following domains: (1) surveillance of antimicrobial prescribing and usage; (2) infection prevention and control practices that mitigate the spread of resistant pathogens; (3) stewardship programs and practices that educate health professionals, the public, and the private sector and nudge each into more appropriate patterns of supply and demand; and (4) a program of innovation, research and development focused on diagnostics, vaccines and alternative treatments to reduce reliance on antimicrobials. This includes the development of novel antimicrobials that expand the currently available arsenal.
c) Given the global dimensions of AMR, a successful One Health approach will require ambitious investments in global AMR mitigation. Given that health infrastructure and resources are limited in low- to middle-income countries, the impacts of AMR will primarily be felt in those settings.
1. Physicians and allied health professionals
a) Be aware that AMR is a serious public health crisis.
b) Know that various Canadian prescribing aides/guidelines are available to assist physicians in choosing appropriate antibiotics and improving practice (e.g., Choosing Wisely Canada).
c) Know that using antibiotics appropriately can help combat AMR and that diagnosis and laboratory testing play a key role. This includes only prescribing antibiotics for conditions that are clinically infectious and of a non-viral nature. Viral infections are the greatest source of antibiotic misuse.
d) Consider delayed prescriptions and/or prioritize follow-up for patients when diagnosis is initially undifferentiated or when symptoms worsen, progress or are prolonged.
e) Know that prevention of infections through hand hygiene, vaccination and appropriate use of antibiotic prophylaxis is evidence based and effective
f) Know that durations of therapy and dosage rates for treating many infections change with time and that you should prescribe antimicrobials for the shortest effective duration (using the narrowest spectrum possible).
g) Consider the potential side effects of antibiotics (including C. difficile and allergic reactions) in prescribing and when counselling patients as to their potential side effects.
h) Engage in conversations with patients about antimicrobials regarding:
i. their appropriate use;
ii. their potential risks;
iii. when to delay, begin or end an antimicrobial prescription (e.g., delayed prescriptions); and
iv. when to seek medical reassessment if symptoms worsen or persist.
i) Ask your local hospital or specialty organization about educational initiatives related to antibiotic prescribing.
j) Collaborate where possible with colleagues in other prescribing professions to reduce unnecessary antimicrobial use.
2. Patients and the Canadian public
a) Be aware that AMR is a significant problem that is linked to the inappropriate use of antimicrobials like antibiotics. Therefore, commit to only taking antibiotics if they are prescribed and only as directed by an authorized health professional.
i. Never share, or use, the antibiotics of others as it may contribute to AMR and have serious consequences for your health.
b) Consider that your expectations about antimicrobials may unduly pressure physicians, and other prescribers, to provide you a prescription when an antimicrobial would not be appropriate or helpful.
c) Engage in a conversation with prescribers about:
i. whether an antimicrobial is necessary;
ii. the risks associated with taking an antimicrobial;
iii. whether there are simpler and safer options to pursue; and
iv. when you should take further actions if your symptoms worsen or do not improve.
d) Rather than keeping antimicrobials in your medicine cabinet, throwing them in the garbage/toilet or sharing them with family or friends, practise a One Health mindset. Dispose of all unused and expired antimicrobials at your local pharmacy. This will limit the spread of resistance and prevent antimicrobials from finding their way into the environment.
e) Help limit resistance by staying up to date with all recommended vaccinations, and practise good hand hygiene.
f) If you or a family member have had personal experiences with AMR, consider sharing them with local politicians (provincial/territorial and federal).
3. Governments (federal, provincial/territorial)
a) (Including internationally) immediately make substantial, long term, coordinated and directly dedicated financial investments in AMR and AMS. Specific areas to prioritize include:
i. AMR and AMS awareness campaigns targeted to the public;
ii. campaigns that support health professionals to incorporate AMS principles into their everyday practice;
iii. detailed, and integrated, action plans based on clear metrics of success and that address the needs of communities, primary care practitioners, patients and health care organizations (including long-term care facilities);
iv. practical surveillance of antimicrobial resistance, purchasing, prescribing and use that maximizes the opportunity to respond to changing landscapes;
v. studying in detail the links, and associated risks, between animal health and agricultural practices and human health;
vi. scaling up local AMS initiatives at the provincial/territorial and national health care delivery levels;
vii. pharmaceutical development pipelines and non-pharmacological treatment options for AMR infections;
viii. inexpensive, accurate and timely point-of-care diagnostic tests (usable in the community, at the bedside or in a clinic) to optimize prescribing; and
ix. fostering clinical research, development and innovation in the fields of AMR and AMS.
b) Scale up coordination between federal and provincial/territorial AMR and AMS activities.
c) Hold regular, high-level meetings of ministers of health, agriculture and finance (both federally and provincially/territorially) to discuss the implications of unchecked AMR and how best to mobilize public finances to address it.
d) Strongly consider an arms-length, national-level taskforce to address AMR and AMS.
e) Strengthen the roles of the chief public health officer and the provincial/territorial chief medical officers in addressing AMR and AMS.
f) Undertake a timely review of the Canadian Antimicrobial Resistance Surveillance System (CARRS) with an emphasis on:
i. scaling up the system;
ii. standardizing all AMR reporting metrics across the country; and
iii. injecting adequate resources into AMR surveillance and tracking antimicrobial usage rates.
g) Establish a permanent review body on infectious disease, including pharmacists, microbiologist and other experts, to evaluate the forthcoming Pan-Canadian Action Plan on AMR and release regular progress reports.
4. Health care institutions and organizations
a) Implement strategic AMR plans that are coordinated, cross-departmental and adopted institution wide. These should be premised on:
i. standardized and comprehensive reporting metrics for AMR and antimicrobial usage;
ii. tailored infection prevention and control programs to screen for and effectively prevent new AMR infections;
iii. improving public and professional awareness of AMR organization wide;
iv. improving conservation measures such as prescribing practices (audit and feedback, incentives programs, etc.); and
v. supporting and incentivizing appropriate prescribing of antimicrobials.
b) Evaluate whether existing policies and procedures, diagnostics and testing capacities, and multidisciplinary and organizational cultures are strategically geared toward combatting AMR.
c) Where possible, develop collaborations with other local health institutions, clinical researchers and community, public and private partners to promote AMS.
5. Accreditation and regulatory bodies
a) Regularly review and establish meaningful criteria for accreditation, ethical codes and regulatory practice standards surrounding AMR and AMS so that practitioners and health institutions can be informed, supported and kept up to date on emerging AMR trends, practices and issues.
b) Adopt profession-specific mandatory requirements for AMR and AMS (proper credentialing and training, regular updating of knowledge and competence for prescribing antimicrobials, appropriate data collection regarding antimicrobial usage, etc.) as part of credentialing.
c) Work to promote, support and enhance existing AMS practices and programs.
d) Collaborate with health institutions, professional health associations and other accreditation and regulatory bodies to implement AMS goals/plans.
6. Colleges and faculties for medicine and allied health professions
a) Promote and support more educational resources for AMS and AMR, throughout the continuum of education (undergraduate, postgraduate and continuing education).
i. Topics for these resources should include (1) awareness of AMR and AMS, (2) appropriate diagnostic testing, (3) strategies to minimize antimicrobial use and (4) personal prescribing practices.
b) Promote and support research on AMR and the implementation and dissemination of effective AMS strategies.
1 Public Health Agency of Canada. Tackling antimicrobial resistance and antimicrobial use: a pan-Canadian framework for action. Ottawa: Public Health Agency of Canada; 2017. Available: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/drugs-health-products/tackling-antimicrobial-resistance-use-pan-canadian-framework-action/tackling-antimicrobial-resistance-use-pan-canadian-framework-action.pdf (accessed 2018 Aug 10).
BACKGROUND TO CMA POLICY
See also CMA Policy Antimicrobial Resistance PD19-08
The world is at the tipping point of a post-antibiotic era. “Worldwide, we are relying more heavily on antibiotics to ensure our medical, nutritional, and economic security; while simultaneously causing the decline of their usefulness with overuse and ill-advised use.” It is estimated that the world’s use of antimicrobials increased by 65% between 2000 and 2015 — mainly in low- to middle-income countries.
Dr. Margaret Chan, the former head of the World Health Organization (WHO), described antimicrobial resistance (AMR) as a slow-moving tsunami for public health. Other experts have characterized AMR as a looming “antibiotic apocalypse,” warning that all countries “will face disastrous consequences if the spread of AMR is not contained.” Others are now calling AMR the “climate change” of health care. According to the UK’s review on AMR, an estimated 10 million people globally will die annually by 2050, and AMR will surpass cancer to become the leading cause of death.
AMR occurs when “microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). … As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.” Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs.” “Nightmare bacteria,” as they have been dubbed, are bacterial strains that no conventional antimicrobial can effectively treat; their incidence is on the rise.
AMR represents a unique challenge for the medical profession as it is estimated that as many as 50% of current antibiotic prescriptions are either inappropriate or unnecessary. In addition, taking an antimicrobial involves potentially considerable exposure to side effects or risk. At stake are many currently routine, and lifesaving, forms of medical treatment. Critically, these include many medications for currently treatable bacterial infections, and many forms of surgery (including cesarean delivery), radiation therapy, chemotherapy and neonatal care.4
THE UNDERLYING DYNAMICS OF AMR
AMR is driven by a complex set of interlocking factors. These include: (1) increased global travel and medical tourism; (2) inappropriate, and unnecessarily high, use of antimicrobials in the agrifood sector; (3) poor medical prescribing practices; (4) inadequate implementation of infection prevention and control measures; (5) lack of knowledge, inappropriate expectations and misuse of antimicrobials on the part of the general public; (6) availability of poor-quality antimicrobials; (7) lack of access to rapid, affordable and accurate rapid diagnostic tools and infrastructure; (8) inadequate and underused surveillance data from AMR surveillance systems; (9) international travel rates; and (10) low commercial interest in, or support for, new antimicrobial research and development.
To make progress on AMR, we need to carefully think about how to address its various drivers. Antimicrobial stewardship (AMS) is a term describing coordinated efforts, at any program level, to: (1) promote the appropriate use of antimicrobials; (2) improve patient outcomes; (3) reduce microbial resistance and preserve the effectiveness of antimicrobials; and (4) decrease the spread of infections caused by multidrug-resistant organisms. AMS efforts are based on the “One Health” approach. These include: (1) surveillance; (2) conservation of existing AM effectiveness; (3) innovation through research and development; and (4) infection prevention and control.
Fundamentally, AMR can be thought of as a collective action problem, similar in character to the problem of climate change.3, While all stakeholders have a role to play in combatting AMR, each has very different resources, abilities and perspectives on AMR. Canada and much of the developed world have the luxury of health infrastructures, finances and regulatory frameworks that can make AMR mitigation possible. But in low- to middle-income countries — places where antibiotics might be the only real health care available — the very discussion of AMS can be perceived as threatening. Simply put, this illustrates the fact that solutions to AMR need to mobilize and leverage a collective strategy that is as broad and as connected as possible. To be successful, these solutions will need to do so in a manner that acknowledges the local reality of health care delivery.
Global investment in antimicrobial research and development is underwhelming, a dynamic described as a “drying up” of the pharmaceutical pipeline.8 This is evidenced by the recent large-scale withdrawal of major pharmaceutical companies from antimicrobial research and development, reflecting the lack of profitability in this area. On the pharmaceutical side, there are clear barriers to companies investing in the development of novel antimicrobials. Underlying factors include: (1) 10-year timelines, and an estimated minimum $1 billion price tag for development; (2) high development failure rates for new antimicrobials; (3) the inevitable emergence of resistance to any newly developed antimicrobial; (4) antimicrobials being offered at relatively cheap dosage rates over shorter durations of use; and (5) the need to preserve the efficacy of any antimicrobial’s future use, which limits their economic viability.8
WHAT ARE THE CANADIAN CONTEXTS?
AMR is already a major costly public health challenge in both the US and Canada. AMR infections are clearly linked to poorer health outcomes, longer hospital stays and higher mortality rates.3 The Public Health Agency of Canada (PHAC) estimates that roughly 18,000 hospitalized Canadians contract drug-resistant infections per year. The Canadian Patient Safety Institute estimates that 8,000 Canadian patients die annually with an AMR-related infection. It is estimated that close to 23 million antibiotic prescriptions are written annually for patients in Canada, the approximate equivalent to 1.6% of the population being on an antimicrobial on any given day.
An action plan in Canada is being developed by PHAC. On the surface, the action plan appears comprehensive in that it outlines a One Health approach.10 However, despite commitments to take comprehensive, measurable action on AMS, Canadian leadership on AMR has historically lagged because of a lack of concrete coordination between PHAC and the provinces and because it has been challenging to implement local initiatives systemically.
Previous shortcomings were highlighted in the Auditor General of Canada’s 2015 report and again in a 2017 issue brief by HealthCareCAN.18 Although efforts continue and the action plan is set for release at some point in 2019, concerns remain that: (1) the scope of coordinated efforts with the provinces and territories requires an interest in cooperation that may not exist between the two levels of government; (2) relative to the scope of the problem, sufficient and dedicated resources won’t be allocated; and (3) efforts on the industrial and agricultural fronts may not be sufficiently coordinated with AMR efforts for human health.
In the spring of 2018 the House of Commons Standing Committee on Health (HESA) released a report outlining 10 recommendations for action on AMR in Canada. Although the federal government “accepted” most of the committee’s recommendations, no meaningful (and dedicated) AMR funding has been announced in advance of the action plan’s launch. Indeed, the federal government’s response to the HESA report sought to downplay the need for either urgent action or additional resources. This was done by pointing to nominal federal AMR efforts over the span of more than a decade.
It should be noted that a small number of excellent localized AMS initiatives exist and have begun yielding promising local AMS results in Canada. AMR and AMS champions such as Choosing Wisely Canada, Do Bugs Need Drugs, and the Association of Medical Microbiology and Infectious Disease Canada have long argued that with proper resourcing, localized initiatives can be scaled up to a systemic level of application within provincial health care systems.
GLOBALLY, WHERE DOES AMR STAND?
Urgent action is required at an international level to combat AMR. Although AMR remains a complex public health challenge, the benefits of AMS are clear. The preservation of these precious resources will save lives and can positively affect both quality of care and health care delivery costs.7,14 Globally, many higher income nations and, increasingly, middle-income countries have now developed AMR/AMS action plans. Like the situation in Canada, these emerging and existing global action strategies remain largely unimplemented. Initial cash infusions into the AM drug development pipeline are beginning to emerge.8
Despite this, experts warn that such investments are too short term and wholly inadequate to address the scope of the looming AMR crisis.8, This reflects the many complexities that exist in the implementation of AMR action plans, owing in large part to: (1) a general lack of resources or prioritization; (2) complacency about AMR as a pressing public health concern; (3) difficulties in generalizing local AMS efforts; (4) coordination between sectorial actors; and (5) a lack of tangible AMR metrics and evidence.
If AMS gains are to be made in low- and middle-income countries, the impact of limited resources in those settings will need to be considered.13 Realistically these countries will require various forms of monetary incentives and assistance to be able to effectively adopt AMR programs. If such support is not provided, human health rights will be affected and global AMS efforts will be undermined. Finally, there are now well-established calls for an international model, even a treaty, to be implemented on AMR/AMS.12,
Organ and Tissue Donation and Transplantation (OTDT) is a rapidly changing area of medical science and practice. Organ and tissue transplantations represent significant lifesaving and life-enhancing interventions that require careful consideration by multiple stakeholders spanning medical disciplines. Technological and pharmacological advancements have made organ and tissue transplantation increasingly viable for treating related medical conditions. Changing social norms have also led to shifting perceptions of the acceptability of organ and tissue donation. Within this context, there is a need for renewed consideration of the ethical issues and principles guiding organ and tissue donation and transplantation in Canada.
The overarching principle that guides OTDT is public trust, which requires that the expressed intent either for or against donation will be honoured and respected within the donation and medical systems, and that the best interests of the potential donor are always of paramount importance; policies and mechanisms that guide OTDT should aim to maintain and foster that public trust. The CMA acknowledges and respects the diverse viewpoints, backgrounds, and religious views of physicians and patients and therefore encourages physicians to confront challenges raised by OTDT in a way that is consistent with both standards of medical ethics and patients’ values and beliefs.
This policy identifies foundational principles to address the challenges surrounding deceased and living donation. In conjunction with applicable laws and regulations in Canada, the Declaration of Istanbul, the World Health Organization (WHO) Guiding Principles on Human Cell, Tissue and Organ Transplantation, and leading clinical practices this policy aims to inform physicians and other interested parties on the guiding principles of OTDT in Canada. This policy is intended to address OTDT in adult populations; the challenges, considerations, legislation, and policy surrounding pediatric and neonatal OTDT are unique and deserve focused attention.
Physicians should be aware of relevant legislation, regulatory requirements, and policies in the jurisdiction in which they practice. Physicians are encouraged to refer to the various Canadian specialty societies that deal directly with OTDT for up-to-date information and policy, as well as innovative techniques and approaches.
The practice of OTDT is of great value to patients and society. The CMA supports the continued development of greater capacity, efficiency, and accessibility in OTDT systems in co-ordination with comprehensive and compassionate end-of-life care for Canadians while acknowledging the importance of justice, informed consent, beneficence, and confidentiality to this practice.
There is a continuous need to improve the efficiency and effectiveness of OTDT in an effort to narrow the gap between demand and supply in what remains a scarce, lifesaving resource. The principle of justice should continue to guide the equitable allocation of organs and tissues in a manner that is externally justifiable, open to public scrutiny, and balances considerations of fairness (e.g., medical need or length of time on the wait-list) with medical utility (e.g., transplantation success). There should be no discrimination based on social status or perceived social worth. Lifestyle or behavioral factors should only be considered when clear evidence indicates that those factors will impact the medical probability of success. OTDT should also not rely on the patient’s ability to pay; such actions are inconsistent with the principles that underlie Canada’s publicly-funded health system. Of note, living donation to a loved one or acquaintance (via a directed donation) is regarded as ethically acceptable if potential donors are informed of all options, including that of donating in a non-directed fashion.
All levels of government should continue to support initiatives to improve the OTDT system, raise public awareness through education and outreach campaigns, and fund ongoing research, such that any Canadian who may wish to donate their tissues or organs are given every reasonable opportunity to do so. Potential donor identification and referral, while legislated in many jurisdictions, is an important area of continued development as failure to identify donors deprives families of the opportunity to donate and deprives patients of potential transplants.
To diminish inequities in the rates of organ donation between jurisdictions, federal and provincial governments should engage in consultations with a view to implementing a coordinated, national strategy on OTDT that provides consistency and clarity on medical and legal standards of informed consent and determination of death, and institutes access to emerging best practices that support physicians, providers, and patients. Efforts should be made to ensure adequate engagement with potential donors from communities that have historically had lower living donor rates to help reduce inequities in access to living donation. Policymakers should also continue to explore and appraise the evidence on policy interventions to improve the rates of organ donation in Canada – for example, see a brief overview of opt-in vs. opt-out donation systems in the background to this policy.
2. INFORMED CONSENT AND VOLUNTARINESS
Organ and tissue donation must always be an autonomous decision, free of undue pressure or coercion. By law, the potential organ donor, or their substitute decision-maker, must provide informed consent. Physicians should direct patients to appropriate resources if that patient has expressed interest to become a donor after their death. If a potential donor has not made an expression of intent for or against donation, substitute decision-makers, families, or loved ones may be approached to provide authorization for donation. It should also be noted that consent indicates a willingness to donate, but that donation itself hinges on factors such as medical suitability and timing.
End-of-life decisions must be guided by an individual's values and religious or philosophical beliefs of what it means to have a meaningful life and death. The autonomy of an individual should always be respected regarding their wish, intent, or registered commitment to become a donor after death. Input from family and loved-ones should always be considered in the context of the potential donor’s wishes or commitments – these situations must be handled on a case-by-case basis with respect for cultural and religious views while maintaining the autonomously expressed wishes of the potential donor. Physicians should make every reasonable effort to be aware and considerate of the cultural and religious views of their patients as they pertain to OTDT. Likewise, Canadian medical schools, relevant subspecialties, and institutions should provide training and continuing professional development opportunities on OTDT, including both medicolegal implications and cultural competency.
To protect the voluntariness of the potential donor’s decision, public appeals to encourage altruistic donation should not seek to compensate potential donors through payment and should not subvert established systems of organ allocation. Any exploitation or coercion of a potential donor must be avoided. However, remuneration from officially sanctioned sources for the purpose of reimbursement of costs associated with living donation (e.g., transfer to another location or lost wages during the procedure), may be considered when no party profits financially from the exchange. The CMA supports proposed amendments to the Criminal Code and the Immigration and Refugee Protection Act that criminalizes or otherwise seeks to prevent the coercive collection and transplantation of organs domestically and internationally (i.e., organ trafficking – see relevant guidelines on trafficking ). The CMA also discourages Canadians from participating in organ tourism as either a recipient or donor; physicians should not take part in transplantation procedures where it is reasonable to suspect that organs have been obtained without the donor’s informed consent or where the donor received payment (from WHO Guiding Principle 7); however, in accordance with physicians’ commitment to the well-being of the patient and the professional responsibilities relating to the patient-physician relationship in the CMA Code of Ethics and Professionalism, physicians have an obligation to treat a post-tranplant patient if requested after the patient has participated in organ tourism; physicians should be aware of any legal or regulatory obligations they may have to report a patient’s organ tourism to national authorities, taking into consideration their duties of privacy and confidentiality to the patient. ,
3. BALANCING BENEFICENCE AND NON-MALEFICENCE
Balancing beneficence and non-maleficence means to: Consider first the well-being of the patient; always act to benefit and promote the good of the patient; provide appropriate care and management across the care continuum; take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm occurs; recognize the balance of potential benefits and harms associated with any medical act; and act to bring about a positive balance of benefits over harms.
Prospective donors can benefit from the knowledge that they can potentially save lives after their own deaths. However, potential donors must not be harmed by the act of donating. In accordance with the Dead Donor Rule, organ or tissue procurement should never be the cause of death. Moreover, the care of the dying patient must never be compromised by the desire to protect organs for donation or expedite death to allow timely organ retrieval. Physicians determining that a potential donor has died should not be directly involved in tissue or organ removal from the donor or subsequent transplantation procedures, nor should they be responsible for the care of any intended recipients of such tissues and organs (from WHO Guiding Principle 2). Leading clinical criteria, in conjunction with legally prescribed definitions of death and procedures, should inform the determination of death before donation procedures are initiated.
DCD should be practiced in compliance with the regulations of individual transplant centers, relevant legislation, and leading Canadian clinical guidelines including the national recommendations for donation after cardiocirculatory death in Canada and the guidelines for the withdrawal of life-sustaining measures. Patients undergoing medical assistance in dying (MAiD) may also be eligible for organ and tissue donation – see relevant policy guidelines.
Living donors are motivated to act primarily for the benefit of the recipient. The perceived acceptability of living donation varies from person to person; living donation is deemed to be ethically acceptable when the potential benefits outweigh the potential risks of living donation; living donation is not ethically acceptable where there is a material risk of death of the donor; living donors must provide informed consent, meet medical and psychological requirements, and receive appropriate follow-up care. It is not necessary for the potential donor to be biologically or emotionally related to the recipient.
4. CONFIDENTIALITY AND PRIVACY
Current practice protects the privacy of both donor and recipient and does not allow donation teams, organ donation organizations, or transplant teams to inform either party of the other’s identity. The continuation of this practice is encouraged at the present time to protect the privacy of both donors and recipients. In addition, healthcare providers should consider the privacy and confidentiality implications of practices employed throughout the assessment and post-operative periods – patient consent should be obtained for practices involving any loss of privacy or confidentiality (e.g. group education sessions, etc.).
A person’s choice about whether or not they intend to donate organs and tissues after their death is individual and, like other health-related information, should be considered private. The right to privacy regarding personal health information extends beyond the declaration of death.
Whenever possible, potential donor and recipients should be cared for and evaluated by separate medical teams. In the case of non-directed donations, it may be necessary for information to be shared between donor and recipient teams (e.g. recipient’s underlying disease and risk for recurrence); however, such information should be limited to what is necessary for making an informed choice. Conversely, the CMA recognizes that the choice and process of directed donation is one that is deeply personal, which is likely to result in the intersection of both donor and recipient pathways of care. In such cases, the same onus of confidentiality may not apply given the choices of the donor and recipient involved.
Approved by the CMA Board of Directors December 2019
The objective of this policy is to provide guidance to physicians and institutions by identifying a set of guiding principles and commitments to promote equity and diversity in medicine (as defined in the Guiding Principles section). We address equity and diversity in medicine to improve circumstances and opportunities for all physicians and learners as part of our efforts to create a more collaborative and respectful culture and practice of medicine. To achieve this, we must redress inequities, bias, and discrimination in learning and practice environments.
Individual protection from bias and discrimination is a fundamental right of all Canadians. By embracing the principles of equity and diversity, we can systematically address root causes and reduce structural barriers faced by those who want to enter the medical profession and those practicing medicine. In so doing, we improve their opportunities for advancement, health, and livelihood.
The principles of equity and diversity are grounded in the fundamental commitment of the medical profession to respect for persons. This commitment recognizes that everyone has equal and inherent worth, has the right to be valued and respected, and to be treated with dignity. When we address equity and diversity, we are opening the conversation to include the voices and knowledge of those who have historically been under-represented and/or marginalized. It is a process of empowerment—where a person can engage with and take action on issues they define as important. Empowerment involves a meaningful shift in experience that fosters belonging in the profession and draws on community supports.
As part of equity and diversity frameworks, inclusion is often articulated to refer to strategies used to increase an individual’s ability to contribute fully and effectively to organisational structures and processes. Inclusion strategies are specific organisational practices or programs focused on encouraging the involvement and participation of individuals from diverse backgrounds to integrate and value their perspectives in decision-making processes. Robust processes for inclusion are a vehicle to achieving equity and diversity. Thus, in this policy, the process of inclusion is understood to be positioned at the nexus of the overarching principles of equity and diversity.
Equity and diversity initiatives can be carefully structured to complement and strengthen merit-based approaches. Enhanced support and appropriate methods of evaluation that increase equity of opportunity (for example, equity in training, hiring processes, and in access to resources) provide all physicians and learners with a fair opportunity to cultivate and demonstrate their unique capabilities and strengths, and to realize their full potential.
Promoting equity and diversity fosters a just professional and learning culture that cultivates the diverse perspectives within it, reflects the communities physicians serve, and promotes professional excellence and social accountability as means to better serve patients. An increasingly diverse medical population provides opportunities for underserviced populations to receive better access to medical services and bolsters the management of clinical cases through the contribution of different points of view. Evidence indicates that when demonstrably more equity and diversity in medicine is achieved, physicians experience greater career satisfaction, health and wellness, and a sense of solidarity with the profession while patients experience improved care and a more responsive and adaptable health care system. Evidence further indicates that realizing the full potential of human capital is an essential driver of innovation and health system development.
This policy is consistent with the CMA Code of Ethics and Professionalism and the CMA Charter of Shared Values and strives to be in the spirit of the recommendations relevant to health made in the report of the Truth and Reconciliation Commission of Canada. The policy is informed by a body of evidence described in the accompanying Background document that includes a Glossary of terms.
A clear set of principles and commitments to improving equity and diversity demonstrates that we hold ourselves accountable to recognizing and challenging behaviours, practices, and conditions that hinder equity and diversity and to promoting behaviours, practices, and conditions that will achieve these goals.
Achieving equity in medicine
Equity refers to the treatment of people that recognizes and is inclusive of their differences by ensuring that every individual is provided with what they need to thrive, which may differ from the needs of others. It is a state in which all members of society have similar chances to become socially active, politically influential, and economically productive through the absence of avoidable or remediable differences among groups of people (defined socially, economically, demographically, or geographically). Equity in the medical profession is achieved when every person has the opportunity to realize their full potential to create and sustain a career without being unfairly impeded by discrimination or any other characteristic-related bias or barrier. To achieve this, physicians must 1) recognize that structural inequities that privilege some at the expense of others exist in training and practice environments and 2) commit to reducing these by putting in place measures that make recruitment, retention, and advancement opportunities more accessible, desirable, and achievable. To that end, physicians must apply evidence-based strategies and support applied research into the processes that lead to inequities in training and practice environments.
Fostering diversity in medicine
Diversity refers to observable and non-observable characteristics which are constructed—and sometimes chosen—by individuals, groups, and societies to identify themselves (e.g., age, culture, religion, indigeneity, ethnicity, language, gender, sexuality, health, ability, socio-economic and family status, geography). The barriers to diversity in medicine are broad and systemic. Individuals and groups with particular characteristics can be excluded from participation based on biases or barriers. Even when they are included, they are often not able to use the full range of their skills and competencies. As with improving equity, the benefits of a more diverse medical profession include improved health outcomes, system-level adaptation, and physician health and wellness. To achieve these benefits, the medical profession must become increasingly diverse by striving to create, foster, and retain physicians and learners who reflect the diversity of the communities they serve and it must be responsive to the evolving (physical, emotional, cultural, and socioeconomic) needs of patients.
Promoting a just professional and learning culture
Physicians value learning and understand that it reflects, and is informed by, the professional culture of medicine. A just professional and learning culture is one of shared respect, shared knowledge, shared opportunity, and the experience of learning together. An environment that is physically and psychologically safe by reducing bias, discrimination, and harassment is critical to creating and sustaining such a culture. To achieve this, the profession must strive to integrate cultural safety by fostering and adopting practices of cultural competence and cultural humility. Physicians and leaders across all levels of training, practice, and health settings, and through formal and informal mentorships, must also promote and foster environments where diverse perspectives are solicited, heard, and appreciated. In this way, diverse individuals are both represented in the professional culture of medicine and actively involved in decision-making processes in all aspects of the profession.
Fostering solidarity within the profession
Solidarity means standing alongside others by recognizing our commonality, shared vulnerabilities and goals, and interdependence. It is enacted through collective action and aims. To show solidarity within the profession means making a personal commitment to recognizing others as our equals, cultivating respectful, open, and transparent dialogue and relationships, and role modelling this behaviour. Solidarity enables each of us to support our colleagues in meeting their individual and collective responsibilities and accountabilities to their patients and to their colleagues. Being accountable to these goals and to each other means taking action to ensure the principles that guide the medical profession are followed, responding justly and decisively when they are not, and continually searching for ways to improve the profession through practice-based learning and experience.
Promoting professional excellence and social accountability
Engaged and informed research and action on equity and diversity is critical to promoting professional excellence and social accountability in medicine as means to better serve patients. Professional excellence is a fundamental commitment of the profession to contribute to the development of and innovation in medicine and society through clinical practice, research, teaching, mentorship, leadership, quality improvement, administration, and/or advocacy on behalf of the profession or the public. Social accountability is a pillar of the commitment to professional excellence by focusing those efforts on fostering competence to address the evolving health needs of the patients and communities physicians are mandated to serve. For care to be socially accountable, and to achieve professional excellence, physicians must provide leadership through advocacy and through action: advocacy about the benefits of addressing equity and diversity to achieve equitable health outcomes; and actions to be responsive to patient, community, and population health needs through high-quality evidence-based patient care.
To accomplish equity and diversity in medicine, organizational and institutional changes will be required across many facets of operation and culture including leadership, education, data gathering/analysis, and continuous improvement through feedback and evaluation of policies and programs. To achieve this, the CMA seeks to provide direction on broad action areas that require further specific actions and development measures in specific recruitment, training, and practice contexts. The CMA recommends:
All medical organizations, institutions, and physician leaders:
A. Take a leadership role in achieving greater equity and diversity by co-creating policies and processes that apply to them, and the individuals therein, in an accountable and transparent manner. This includes:
1. Identifying and reducing structural inequities, barriers, and biases that exist in training and practice environments to create fair opportunities for all physicians and learners; and providing the appropriate platforms, resources, and training necessary to do so to effect change collaboratively.
2. Practicing and promoting cultural safety, cultural competence, and cultural humility.
3. Providing training on implicit bias, allyship, cultural safety, cultural competence, and cultural humility, structural competence, and the value of diversity in improving health outcomes.
4. Ensuring a process is in place to review all workforce and educational policies, procedures, and practices toward considering their impact on equity and diversity. Areas of consideration include (but are not limited to) recruitment, promotion, pay, leave of absence, parental leave, resources and support, and working/learning conditions and accommodations.
5. Ensuring safe, appropriate, and effective avenues exist for those who may have experienced discrimination, harassment, or abuse in training and practice environments to report these events outside of their supervisory/promotional chain. Those experiencing these events should also be able to seek counselling without the fear of negative consequences.
6. Working towards creating and appropriately funding equity and diversity Chairs, Committees, or Offices with a mandate to investigate and address issues in equity and diversity.
7. Promoting and enabling formal and informal mentorship and sponsorship opportunities for historically under-represented groups.
B. Encourage the collection and use of data related to equity and diversity through research and funding, and, specifically, review their data practices to ensure:
1. Historically under-represented groups are meaningfully engaged through the co-development of data practices.
2. Data regarding the representation of under-represented groups is being systematically and appropriately collected and analyzed.
3. Information collected is used to review and inform internal policy and practice with the aim of reducing or eliminating system-level drivers of inequity.
4. Findings relating to these data are made accessible.
C. Support equity and diversity in recruitment, hiring, selection, appointment, and promotion practices by:
1. Requesting and participating in training to better understand approaches and strategies to promote equity and diversity, including implicit bias and allyship training that highlights the roles and responsibilities of all members of the community with emphasis on self-awareness, cultural safety, and sensitivity to intersectionalities.
2. Studying organizational environments and frameworks and identifying and addressing hiring procedures, especially for leadership and executive positions, that perpetuate institutional inequities and power structures that privilege or disadvantage people.
3. Adopting explicit criteria to recruit inclusive leaders and to promote qualified candidates from historically under-represented groups in selection processes.
Additional recommendations for institutions providing medical education and training:
1. Establishing programs that espouse cultural safety, cultural competence, and cultural humility.
2. Encouraging all instructors develop competencies including non-discriminatory and non-stereotyping communication, awareness of intersectionality, and cultural safety.
3. Providing training programs, at the undergraduate level onwards, that include awareness and education around stereotypes (gender and otherwise), intersectionalities, and the value of diversity in improving health outcomes.
4. Providing diversity mentorship programs that aim to support diverse candidates through education and training to graduation.
5. Promoting and funding student-led programs that create safe and positive spaces for students and principles of equity and diversity.
6. Ensuring recruitment strategies and admission frameworks in medical schools incorporate more holistic strategies that recognize barriers faced by certain populations to enable a more diverse pool of candidates to apply and be fairly evaluated.
7. Developing learning communities (such as undergraduate pipelines described in the background document) to promote careers in medicine as a viable option for individuals from historically under-represented communities.
Approved by the CMA Board of Directors December 2019
Homeless and vulnerably housed populations are heterogeneous
and continue to grow in numbers in urban and
rural settings as forces of urbanization collide with gentrification and austerity policies.2
Collectively, they face dangerous living conditions and marginalization within health care systems.3
However, providers can improve the health of people who
are homeless or vulnerably housed, most powerfully by following
evidence-based initial steps, and working with communities and
adopting anti-oppressive practices.1,4,5
Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6
Under such conditions, individuals and families face intersecting
social, mental and physical health risks that significantly increase
morbidity and mortality.7,8 For example, people who are homeless
and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports
that people who experience homelessness face life expectancies
as low as 42 years for men and 52 years for women.7
A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth,
Indigenous people (Box 1), immigrants, older adults and people
from rural communities.13,14 For example, family homelessness
(and therefore homelessness among dependent children and
youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of
the estimated 235 000 homeless people in Canada, 27.3% were
women, 18.7% were youth, 6% were recent immigrants or
migrants, and a growing number were veterans and seniors.10
Practice navigators, peer-support workers and primary care
providers are well placed to identify social causes of poor health
and provide orientation to patient medical homes.16,17 A patient’s
medical home is “a family practice defined by its patients as the
place they feel most comfortable presenting and discussing their
personal and family health and medical concerns.”18 Medical
care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated
with other services in the health care system and the community”
(https://patientsmedicalhome.ca). Primary care providers are
also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19
GUIDELINE VULNERABLE POPULATIONS CPD
Clinical guideline for homeless and vulnerably
housed people, and people with lived
Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH,
Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD,
Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD,
Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW,
Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD,
Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA,
Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD
n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199
Clinical assessment and care of homeless and vulnerably housed
populations should include tailoring approaches to a person’s
gender, age, Indigenous heritage, ethnicity and history of
trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed
populations, permanent supportive housing is strongly
recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric
support, are recommended as an initial step to support primary
care and to address existing mental health, substance use and
Harm-reduction interventions, such as supervised consumption
facilities, and access to pharmacologic agents for opioid use
disorder, such as opioid agonist treatment, are recommended
for people who use substances.
MARCH 9, 2020
ISSUE 10 E241
However, the social and health resources available to homeless
and vulnerably housed people may vary based on geographic
setting, municipal resources, housing coordination, and patients’
mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities
for care, patient mistrust of the health care system or limited
access to health services.3
Homeless and vulnerably housed people can benefit from
timely and effective health, addiction and social interventions.
Our guideline provides initial steps for practice, policy and future
research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values
such as trauma-informed and patient-centred care, and dignity
are needed to foster trust and develop sustainable therapeutic
relationships with homeless and vulnerably housed people.20,21
The purpose of this clinical practice guideline is to inform providers
and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The
guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers.
Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the
many etiologies of homelessness, such as childhood trauma, the
housing market, or the root causes of low social assistance rates
and economic inequality. Rather, this guideline aims to reframe
providers’ approach toward upstream interventions that can
prevent, treat and work toward ending the morbidity and mortality associated with homelessness.
A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led
team.22 This process recognizes the distinct rights of Indigenous
Peoples, including the right to develop and strengthen their own
economies, social and political institutions; the direct links
between historic and ongoing colonial policies and Indigenous
homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples.
The steering committee and guideline panel members developed
and approved recommendations to improve social and health
outcomes for homeless and vulnerably housed people. The order
of these recommendations highlights priority steps for homeless
health care. We list a summary of the recommendations in Table 1
and we present our list of good practice statements in Table 2.
These good practice statements are based on indirect evidence
and support the delivery of the recommendations.
The methods used to develop the recommendations are
described later in this document. A summary of how to use this
guideline is available in Box 2.
Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to
local housing coordinator or case manager (i.e., call 211 or
via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation).
Our systematic review (Tim Aubry, University of Ottawa, Ottawa,
Ont.: unpublished data, 2020) identified 14 trials on permanent
supportive housing (PSH).30–43 Several trials across Canada and the
United States showed that PSH initiatives house participants more
rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30
increase the number of people who maintain stable housing at
2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and
significantly increase the percentage of days spent stably
housed.41 No trials showed a significant improvement in mental
health symptoms compared with standard care.30,31,33,34,41,42
Two studies found that the mental health of PSH participants did
not improve as much as that of usual care participants (e.g., mean
difference –0.49, 95% CI –0.85 to –0.12).30,31
The At Home/Chez Soi trial showed small improvements in quality
of life for high-needs (adjusted standardized mean difference 0.15,
95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37,
95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41
Youth receiving PSH saw larger improvements in their quality of life
during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24),
which diminished over time (mean difference 7.29, 95% CI –1.61 to
16.18).44 No trials showed a significant improvement in substance use
compared with standard care.30,33,41–43 Most trials reported no effect of
PSH on acute care outcomes (e.g., number of emergency department
visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital
admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found
no effect of PSH on job tenure, hours of work per week or hourly wage
compared with standard care.46 Participants receiving PSH may have
increased odds of employment, but this depends on the severity of
participant needs.46 One trial found no effect on income outcomes.46
Box 1: Indigenous homelessness
Indigenous homelessness is a term used to describe First Nations,
Métis and Inuit individuals, families or communities who lack
stable, permanent and appropriate housing, or the immediate
prospects, means or ability to acquire such housing. However, this
term must be interpreted through an Indigenous lens to
understand the factors contributing to this condition. These
factors include individuals, families and communities isolated
from their relationships to land, water, place, family, kin, each
other, animals, cultures, languages and identities as well as the
legacy of colonialism and genocide.11 It is estimated that urban
Indigenous people are 8 times more likely to experience
homelessness than the general population.11,12
The certainty of the evidence was rated moderate, because
blinding of participants and personnel was not feasible in any of
the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which
could introduce high risks of detection and performance biases.
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation).
We identified 10 trials on income-assistance interventions, including
rental assistance,47–56 financial empowerment,47 social enterprise
interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that
income-assistance interventions have on housing stability (Gary
Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020).
Rental assistance increased the likelihood of being stably housed
(OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with
case management increased the number of days in stable housing
per 90-day period compared with case management alone (mean
Table 1: Summary of evidence-based recommendations
Recommendations and clinical considerations Grade rating*
Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call
211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system.
Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized
populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those
with disabilities, refugees and migrants.
Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or
living in a low-income household
Assist individuals with income insecurity to identify income-support resources and access income.
Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products
Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs
(including mental illness and/or substance use)
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with
substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to
intensive case management, assertive community treatment or critical time intervention where available.
Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar
with local access points and less intensive community mental health programs.
Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in
collaboration with a public health or community health centre for linkage to pharmacologic interventions.
Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers
to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT
access and options in your jurisdiction, in particular for buprenorphine.
Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services
(e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as
public health or community health centre or local community services centre.
Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be
made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/
Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited.
*See Box 2 for definitions.
†211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and
referrals to health, human and social service organizations.
ISSUE 10 E243
difference 8.58, p < 0.004).55 Compensated work therapy was found
to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No
income interventions showed an effect on mental health
The impact of these interventions on substance use outcomes
were mixed. Provision of housing vouchers did not affect substance
use over 3 years;55 however, compensated work therapy showed
immediate reductions in drug (reduction: –44.7%, standard error [SE]
12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p =
0.001), as well as the number of substance use–related physical
symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found
on overall quality-of-life, finances, health and social relations scores.
Provision of housing vouchers resulted in higher family-relations
score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated
with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to
improve employment rates only when there was high fidelity to the
model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54
Provision of housing vouchers had no effect on monthly income.55
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance
programs after completing the study had incentives to underreport
symptoms, which introduced high risk for measurement bias.
Identify history of severe mental illness, such as psychotic or
mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex
Ensure access to local community mental health programs,
psychiatric services for assessment and linkage to intensive
case management, assertive community treatment or critical
time intervention where available (low certainty, conditional
Our systematic review examined the effectiveness of standard
case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention
among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa,
Ottawa, Ont.: unpublished data, 2020). We included a total of
56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73
16 trials on intensive case management74–89 and 5 trials on critical
Box 2: How to use and understand this GRADE guideline
This guideline supplies providers with evidence for decisions
concerning interventions to improve health and social outcomes
for people who are homeless or vulnerably housed. This guideline
is not meant to replace clinical judgment. Statements about
clinical considerations, values and preferences are integral parts of
the recommendations meant to facilitate interpretation and
implementation of the guideline. Recommendations in this
guideline are categorized according to the Grading of
Recommendations Assessment, Development and Evaluation
(GRADE) system as strong or conditional recommendations.
Strong recommendations indicate that all or almost all fully
informed patients would choose the recommended course of
action, and indicate to clinicians that the recommendation is
appropriate for all or almost all individuals. Strong
recommendations represent candidates for quality-of-care criteria
or performance indicators.
Conditional recommendations indicate that most informed
patients would choose the suggested course of action, but an
appreciable minority would not. With conditional
recommendations, clinicians should recognize that different
choices will be appropriate for individual patients, and they should
help patients arrive at a decision consistent with their values and
preferences. Conditional recommendations should not be used as
a basis for standards of practice (other than to mandate shared
Good practice statements represent common-sense practice, are
supported by indirect evidence and are associated with assumed
large net benefit.
Clinical considerations provide practical suggestions to support
implementation of the GRADE recommendation.
GRADE certainty ratings
High: further research is very unlikely to change our confidence in
the estimate of effect.
Moderate: further research is likely to have an important impact on
the confidence in the estimate of effect and may change the estimate.
Low: further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change
Very low: any estimate of the effect is very uncertain.
Table 2: Good practice statements to support delivery of care
Good practice statement
1. Homeless and vulnerably housed populations
should receive trauma-informed and personcentred care.
2. Homeless and vulnerably housed populations
should be linked to comprehensive primary
care to facilitate the management of multiple
health and social needs.
3. Providers should collaborate with public health
and community organizations to ensure
programs are accessible and resources
appropriate to meet local patient needs.
Of 10 trials on standard case management, 10 evaluated
housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a
time-limited residential case management in which participants
in all groups accessed substantial levels of services.57 A program
tailored to women reduced the odds of depression at 3 months
(OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in
the women’s overall mental health status (mean difference 4.50,
95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female
participants receiving nurse-led standard case management
compared with those receiving standard care.60 Few studies
reported on substance use, quality of life, employment or
Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are
mixed. Two trials found that participants receiving the treatment
reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect
on episodes of homelessness or number of days homeless.66,73
Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department
(mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental
health outcomes, including psychiatric symptoms, substance
use, or income-related outcomes between the treatment and
Intensive case management reduced the number of days
homeless (pooled standardized mean difference –0.22, 95% CI
–0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in
psychological symptoms between the treatment and control
groups. However, 1 trial reported significantly greater reductions
in anxiety, depression and thought disturbances after 24 months
(mean difference change from baseline –0.32, p = 0.007), as well
as improved life satisfaction (mean difference 1.23, p = 0.001)
using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use
were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use
behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department
(mean difference 19%, p < 0.05) but did not have shorter hospital
stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on
income received from employment; however, income received
by participants through public assistance increased (e.g., mean
difference 89, 95% CI 8 to 170).78,85
Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the
odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the
final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard
care,95 but did not spend more days rehoused.90 Adults receiving
critical time intervention showed significant improvements in
psychological symptoms (mean difference –0.14, 95% CI –0.29 to
0.01).90 However, findings for children’s mental health were
mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86),
whereas changes for children aged 6–10 years and 11–16 years
were not significant.93 There were no significant effects of critical
time intervention on substance-use,90 quality-of-life90,92 or
income-related outcomes.96 Two trials reported mixed findings
on hospital admission outcomes; in 1 study, allocation to critical
time intervention was associated with reduced odds of hospital
admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of
nights in hospital (p < 0.05) in the final 18 weeks of the trial.97
However, another study reported a greater total number of
nights in hospital for the treatment group compared with usual
care (1171 v. 912).98
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias.
Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by
referral to an addiction specialist, potentially in collaboration
with public health or community health centre for linkage to
pharmacologic interventions (low certainty, conditional
We conducted a review of systematic reviews on pharmalogic
interventions for opioid use disorder.99 Twenty-four reviews,
which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general
populations.100–123 We expanded our inclusion criteria to general
populations, aware that most studies among “general populations” had a large representation of homeless populations in
their samples. We did not identify any substantial reason to
believe that the mechanisms of action of our interventions of
interest would differ between homeless populations who use
substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on
the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and
hydromorphone for treatment of opioid use disorder.
We found pooled all-cause mortality rates of 36.1 and 11.3 per
1000 person years for participants out of and in methadone
maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to
3.86), and mortality rates of 9.5 per 1000 person years for those
not receiving buprenorphine maintenance therapy compared
with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific
mortality rates were similarly affected, with pooled overdose
mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates
of 4.6 and 1.4 per 1000 person years out of and in buprenorphine
maintenance therapy.116 Compared with nonpharmacologic
approaches, methadone maintenance therapy had no significant
ISSUE 10 E245
effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With
respect to morbidity, pharmacologic interventions for opioid use
disorder reduced the risk of hepatitis C virus (HCV) acquisition
(risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103
Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with
reduced illicit opioid use (standardized mean difference –1.17,
95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment
expanded access to treatment for patients unlikely to enrol in
methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear;
however, use of methadone was found to show better benefits
than nonpharmacologic interventions for retention (risk ratio
4.44, 95% CI 3.26 to 6.04).110
The certainty of evidence ranged from very low to moderate,
primarily because of inconsistency, high risk of bias and evidence
from nonrandomized studies.
Identify problematic substance use, including alcohol or other
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised
consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community
health centre or les centres locaux de services communautaires (low certainty, conditional recommendation).
We conducted a review of systematic reviews on supervised
consumption facilities and managed alcohol programs.99 Two
systematic reviews, which included 90 unique observational
studies and 1 qualitative meta-synthesis reported on supervised
consumption facilities.124–126 For managed alcohol programs,
1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129
Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per
100 000 person years, p = 0.048), compared with 9% in the rest of
the city (Vancouver).124 There were 336 reported opioid overdose
reversals in 90 different individuals within the Vancouver facility
over a 4-year period (2004–2008).125 Similar protective effects
were reported in Australia and Germany. Observational studies
conducted in Vancouver and Sydney showed that regular use of
supervised consumption facilities was associated with decreased
syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe
reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space
injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter)
and fostered access to broader health support.125,126 Attendance
at supervised consumption facilities was associated with an
increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio
1.57, 95% CI 1.02 to 2.40).125
Evidence on supervised consumption facilities was rated very
low to low, as all available evidence originated from nonrandomized studies.
There was a lack of high-quality evidence for managed alcohol
programs. Few studies reported on deaths among clients of these
programs.128 The effects of managed alcohol programs on hepatic
function are mixed, with some studies reporting improvement in
hepatic laboratory markers over time, and others showing
increases in alcohol-related hepatic damage;129 however, this may
have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with
medical and social services.128 Clients experienced significantly
fewer social, health, safety and legal harms related to alcohol
consumption.129 Individuals participating in these programs had
fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129
Cost effectiveness and resource implications
Permanent supportive housing
We found 19 studies assessing the cost and net cost of housing
interventions.30,41,45,130–145 In some studies, permanent supportive
housing interventions were associated with increased cost to the
payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the
intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies,
however, employed a pre–post design.135,139,141,145 Moreover,
1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased
quality-adjusted life years, with an incremental cost-effectiveness
ratio of US$62 493 per quality-adjusted life year.136 Compared
with usual care, PSH was found to be more costly to society (net
cost Can$7868, 95% CI $4409 to $11 405).138
Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving
case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received
income assistance incurred additional costs of US$58 (95% CI $4
to $111) from the perspective of the payer, US$50 (95% CI –$17 to
$117) from the perspective of the health care system and US$45
(95% CI –$19 to $108) from the societal perspective. The benefit
gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146
Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150
Findings of these studies were mixed; the total cost incurred by
clients of standard case management was higher than that of
clients receiving usual or standard care61,88 and assertive
community treatment,67,147 but lower compared with a US clinical
case-management program that included housing vouchers and
intensive case management.55 Cost-effectiveness studies using a
societal perspective showed that standard case management
was not cost effective compared with assertive community
treatment for people with serious mental disorders or those with
a concurrent substance-use disorder, as it was more expensive.67
For intensive case management, the cost of supporting housing
with this program could be partially offset by reductions in the use
of emergency shelters and temporary residences.41 Intensive case
management is more likely to be cost effective when all costs and
benefits to society are considered.41 A pre–post study showed that
providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150
Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We
identified only 1 study on the cost effectiveness of critical time
intervention that reported comparable costs (US$52 574 v.
US$51 749) of the treatment compared with the usual services
provided to men with severe mental illness.96
Interventions for substance use
We identified 2 systematic reviews that reported findings from
6 studies in Vancouver on the cost effectiveness of supervised
consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating
costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of
incident HCV infection.
Providers can, in partnership with directly affected communities,
employ a range of navigation and advocacy tools to address the
root causes of homelessness, which include poverty caused by
inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the
propagation of violence in homes and communities, inadequate
supports for patients and families living with disabilities or going
through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to
the patient’s needs and demographics, taking into account
access to services, personal preferences and other illnesses.152
Providers should also recognize the social and human value
of accepting homeless and vulnerably housed people into their
clinical practices. The following sections provide additional evidence for underserved and marginalized populations.
A scoping review of the literature on interventions for homeless
women (Christine Mathew, Bruyère Research Institute, Ottawa,
Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156
and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused
specifically on homeless and vulnerably housed women. Findings
showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women
with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster
care placements, allowing women to maintain the integrity of their
family unit.158 As well, Housing First programs for families, critical
time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress,
increased self-esteem and improved quality of life for women and
their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among
homeless women. We suggest that providers focus on patient
safety, empowerment among women who have faced genderbased violence, and improve access to resources, including
income, child care and other social support services.
A systematic review on youth-specific interventions reported
findings from 4 systematic reviews and 18 RCTs.162 Permanent
supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in
significant improvements in depression scores, and family-based
therapies are also promising, resulting in reductions in youth
substance use through restoring the family dynamic. Findings on
motivational interviewing, skill building and case-management
interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits.
Refugee and migrant populations
A qualitative systematic review on homeless migrants (Harneel
Kaur, University of Ottawa, Ottawa, Ont.: unpublished data,
2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging
and access to social services, such as housing. However, employment opportunities provided a sense of independence and
improved social integration.
Composition of participating groups
In preparation for the guideline, we formed the Homeless Health
Research Network (https://methods.cochrane.org/equity/
projects/homeless-health-guidelines), composed of clinicians,
academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P.
[chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was
assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario,
Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of
homelessness (herein referred to as “community scholars”180)
were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the
participating groups and monitored competing interests.
The steering committee decided to develop a single guideline
publication informed by a series of 8 systematic reviews. The
ISSUE 10 E247
steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical
topic experts and community scholars who were responsible for
providing contextual expertise.
The steering committee also assembled a technical team,
which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the
responsibility to provide external review of the evidence and
drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists,
psychiatrists, public health professionals, people with lived
experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of
interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/
Selection of priority topics
We used a 3-step modified Delphi consensus method (Esther
Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020) to select priority health conditions for marginalized
populations experiencing homelessness or vulnerable housing.
Briefly, between May and June 2017, we developed and conducted
a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank
and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to
keep in mind 3 priority-setting criteria when considering the
unique challenges of implementing health care for homeless or
vulnerably housed people: value added (i.e., the opportunity for a
unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e.,
the number of people who may have a disease or condition).181
The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care,
delivering care coordination and case management, and facilitating
access to adequate income. The priority marginalized populations
identified included Indigenous people; women and families; youth;
people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère
Research Institute, Ottawa, Ont.: unpublished data, 2020). Each
working group then scoped the literature using Google Scholar and
PubMed to determine a list of interventions and terms relating to
each of the priority-need categories. Each working group came to
consensus on the final list of interventions to be included (Table 3).
We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development
of this clinical guideline, including the identification of clinical
questions, systematic reviews of the best available evidence,
Table 3: Descriptions of priority-need interventions
Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the
provision of individualized supportive services that are tailored to participants’ needs and choices,
including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing
housing) with permanent supportive housing.
Benefits and programs that improve socioeconomic status. This may include assistance that directly
increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and
compensated work therapy) in this category.
Standard case management allows for the provision of an array of social, health care and other services
with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of
services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each
case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental
illness by a multidisciplinary group of health care workers in the community. This team should be available
24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case
management is administered by a critical time intervention worker and is a time-limited service, usually
lasting 6–9 months.
Pharmacologic interventions for
substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine,
diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or
intranasally (e.g., naloxone).
Harm reduction for substance
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use
substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated
alcohol to support residents with severe alcohol use disorder.
assessment of the certainty of the evidence and development of
recommendations.182 We conducted a series of systematic reviews
to answer the following clinical question:
Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions
be considered for people with lived experience of homelessness?
Systematic reviews for each intervention were driven by a logic
model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search
terms, can be found in Appendix 3, available at www.cmaj.ca/
lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and
comparisons according to published a priori protocols.183–186 We
used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The
technical team reviewed titles, abstracts and full texts of identified
citations, selected evidence for inclusion and compiled evidence
reviews, including cost-effectiveness and resource-use data, for
consideration by the guideline panel. The technical team collected
and synthesized data on the following a priori outcomes: housing
stability, mental health, quality of life, substance use, hospital
admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty
of evidence using the GRADE approach. Where pooling of results
was not appropriate, we synthesized results narratively.
In addition to the intervention and cost-effectiveness reviews,
the technical team conducted 3 systematic reviews to collect
contextual and population-specific evidence for the populations
prioritized through our Delphi process (women, youth, refugees
and migrants) (Christine Mathew, Bruyère Research Institute,
Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University
of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally,
we conducted 1 qualitative literature review to capture patient
values and preferences, focused on the experiences of people
who are homeless in engaging with our selected interventions.20
Drafting of recommendations
The steering committee hosted a 2-day knowledge-sharing
event, termed the “Homeless Health Summit,” on Nov. 25–26,
2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all
intervention reviews were presented and discussed according to
the GRADE Evidence to Decision framework.187 After the meeting,
the steering committee drafted GRADE recommendations (Box 2)
through an iterative consensus process. All steering-committee
members participated in multiple rounds of review and revision
of the drafted clinical recommendations.
Guideline panel review
We used the GRADE Evidence to Decision framework to facilitate
the development of recommendations187–189 (Appendix 4, available
We used GRADEpro and the Panel Voice software to obtain input
from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided
considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance
of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off.
Good practice statements
We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A
good practice statement characteristically represents situations in
which a large and compelling body of indirect evidence strongly
supports the net benefit of the recommended action, which is
necessary for health care practice.191–193 Guideline-development
groups consider making good practice statements when they have
high confidence that indirect evidence supports net benefit, there
is a clear and explicit rationale connecting the indirect evidence,
and it would be an onerous and unproductive exercise and thus a
poor use of the group’s limited resources to collect this evidence.
The steering committee came to a consensus on 3 good practice
statements based on indirect evidence.
Identification of implementation considerations
We completed a mixed-methods study to identify determinants
of implementation across Canada for the guideline (Olivia
Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost
(affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to
implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019;
Gatineau, Que., July 18, 2019) with relevant stakeholders in the
field of homeless health to analyze our implementation data.
Management of competing interests
Competing interests were assessed using a detailed form adapted
from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the
Elsevier sample coauthor agreement form for a scientific project,
contingencies and communication.195 These forms were collected
at the start of the guideline activities for the steering committee,
guideline panel and community scholars. All authors submitted
an updated form in June 2019 and before publication.
The management committee iteratively reviewed these statements and interviewed participants for any clarifications and
concerns. A priori, the management committee had agreed that
major competing interests would lead to dismissal. There were
no competing interests declared.
Our mixed-methods study (Olivia Magwood, Bruyère Research
Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to
implement, identified the following concerns regarding implementation of this guideline.
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Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to
PSH programs and informing their patients about the resources
available in the community.
The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as
administrative and human resources concerns. For example, not
all primary care providers work in a team-based comprehensive
care model and have access to a social worker or care coordinator
who can help link the patient to existing services. Furthermore,
wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible
Allied health practitioners and physicians do not always agree
with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients
and less experience exploring social determinants of health, such
as housing or income. The initial steps outlined in this guideline
would come at an opportunity cost for them. Stigma attached to
the condition of homelessness was recognized as an important
barrier to care for homeless populations.
Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to
increase the housing supply, income supports and human
resources. However, supervised consumption facilities, with their
range of benefits, were perceived as cost-saving.
Many interventions have the potential to increase health
equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the
initial steps and advocate on a systematic level to increase availability of services.
Suggested performance measures
We developed a set of performance measures to accompany this
guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness
or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for
income assistance over 1 year.
The proportion of eligible adults using opioids who are
offered opioid agonist therapy over 1 year.
The Homeless Health Research Network will be responsible for
updating this guideline every 5 years.
This guideline complements other published guidelines. This
current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous
leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020).
The World Health Organization has developed guidelines to
promote healthy housing standards to save lives, prevent disease
and increase quality of life.196 Other guidelines specific to opioid
use disorder exist,197,198 including 1 for “treatment-refractory”
patients.199 In the United Kingdom, the National Institute for
Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National
Health Care for the Homeless Council in the US has adapted best
practices to support front-line workers caring for homeless
How is this guideline different?
This guideline distills initial steps and evidence-based
approaches, to both homeless and vulnerably housed people,
with the assistance of patients and other stakeholders. It also
introduces a new clinical lens with upstream interventions that
provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the
experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we
hope that our stakeholder engagement inspires and equips
future students, health providers and the public health community to implement the initial step recommendations.
Gaps in knowledge
Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general
housed populations. As primary care expands its medical home
models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in
this guideline. Indeed, clinical research can refine how providers
use the initial steps protocol: housing, income, case management
and addiction. With improved living conditions, care coordination
and continuity of care, research and practice can shift to treatable
conditions, such as HIV and HCV infection, substance use disorder,
mental illness and tuberculosis.203
Medical educators will also need to develop new training
tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many
of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and
case management. Interdisciplinary primary care research and
maintenance of linkages to primary care will benefit from new
homeless health clinic networks. Monitoring transitions in care
and housing availability will be an important research goal for
Canada’s National Housing Strategy and the associated Reaching
Homelessness has become a health emergency. Initial steps in
addressing this crisis proposed in this guideline include strongly
recommending PSH as an urgent intervention. The guideline also
recognizes the trauma, disability, mental illness and stigma
facing people with lived homelessness experience and thus recommends initial steps of income assistance, intensive case management for mental illness, and harm-reduction and addictiontreatment interventions, including access to opioid agonist
therapy and supervised consumption facilities.
The successful implementation of this guideline will depend
on a focus on the initial recommendations, trust, patient safety
and an ongoing collaboration between primary health care,
mental health providers, public health, people with lived experience and broader community organizations, including those
beyond the health care field.
1. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada:
research lessons and priorities. Can J Public Health 2005;96(Suppl 2):S23-9.
2. 31 days of promoting a better urban future: Report 2018. Nairobi (Kenya): UN
Habitat, United Nations Human Settlement Programme; 2018. Available:
-UN-Habitat-Urban-October-Report.pdf (accessed 2019 Apr. 1).
3. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of welcomeness
and unwelcomeness in healthcare encounters. J Gen Intern Med 2007;22:1011-7.
4. Coltman L, Gapka S, Harriott D, et al. Understanding community integration in
a housing-first approach: Toronto At Home/Chez Soi community-based
research. Intersectionalities 2015;4:39-50.
5. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet
6. Canadian definition of homelessness. Toronto: Canadian Observatory on
Homelessness; 2012. Available: www.homelesshub.ca/sites/default/files/
attachments/Definition of Homelessness.pdf (accessed 2019 Apr. 1).
7. Hwang SW, Wilkins R, Tjepkema M, et al. Mortality among residents of shelters,
rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009;339:
8. Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among
users of hostels for homeless people in Copenhagen. BMJ 2003;327:81.
9. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income
countries: descriptive epidemiology, health consequences, and clinical and
policy recommendations. Lancet 2014;384:1529-40.
10. Gaetz S, Dej E, Richter T, et al. The state of homelessness in Canada 2016.
Toronto: Canadian Observatory on Homelessness Press; 2016.
11. Thistle J. Indigenous definition of homelessness in Canada. Toronto: Canadian
Observatory on Homelessness Press; 2017.
12. Belanger YD, Awosoga O, Head GW. Homelessness, urban Aboriginal people,
and the need for a national enumeration. Aboriginal Policy Studies 2013;2:
13. Taylor M. How is rural homelessness different from urban homelessness?
Toronto: The Canadian Observatory on Homelessness/Homeless Hub; 2018.
-urban-homelessness (accessed 2019 Feb. 6).
14. Rodrigue S. Hidden homelessness in Canada. Cat no 75-006-X. Ottawa: Statistics Canada; 2016.
15. Gulliver-Garcia T. Putting an end to child & family homelessness in Canada.
Toronto: Raising the Roof; 2016.
16. Andermann A.; CLEAR Collaboration. Taking action on the social determinants
of health in clinical practice: a framework for health professionals. CMAJ 2016;
17. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical
home: a systematic review. Ann Intern Med 2013;158:169-78.
18. A new vision for Canada: family practice — the patient’s medical home 2019. Mississauga (ON): The College of Family Physicians of Canada; 2019.
19. Declaration of Alma-Ata. Proceedings of the International Conference on Primary
Health Care, Alma-Ata; 1978 Sept. 6–12. Geneva: World Health Organization.
20. Magwood O, Leki VY, Kpade V, et al. Common trust and personal safety issues:
A systematic review on the acceptability of health and social interventions for
persons with lived experience of homelessness. PLoS One 2019;14:e0226306.
21. Luchenski S, Maguire N, Aldridge RW, et al. What works in inclusion health:
overview of effective interventions for marginalised and excluded populations.
22. Thistle JA, Laliberte N. Pekiwewin (Coming Home): Clinical practice guidelines
for health and social service providers working with Indigenous people experiencing homelessness. Verbal concurrent session presented at the Canadian
Alliance to End Homelessness Conference, 2019 Nov. 4; Edmonton.
23. Stewart MA. Effective physician-patient communication and health outcomes:
a review. CMAJ 1995;152:1423-33.
24. Racine N, Killam T, Madigan S. Trauma-informed care as a universal precaution: beyond the adverse childhood experiences questionnaire. JAMA Pediatr
2019 Nov. 4 [Epub ahead of print]. doi: 10.1001/jamapediatrics.2019.3866.
25. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment
Health Nurs 2015;36:698-709.
26. Hopper E, Bassuk E, Olivet J. Shelter from the storm: trauma-informed care in
homelessness services settings. Open Health Serv Policy J 2009;2:131-51.
27. A new vision for Canada: family practice — The patient’s medical home. Mississauga (ON): College of Family Physicians of Canada; 2019. Available: www.
cfpc.ca/A_Vision_for_Canada (accessed 2019 Dec. 2).
28. Valaitis RK, O’Mara L, Wong ST, et al. Strengthening primary health care
through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors. Prim Health Care Res Dev 2018;19:378-91.
29. Akhtar-DaneshN, Valaitis R, O’Mara L, et al. Viewpoints about collaboration between
primary care and public health in Canada.BMC Health Serv Res 2013;13:311.
30. Aubry T, Goering P, Veldhuizen S, et al. A multiple-city RCT of housing first with
assertive community treatment for homeless Canadians with serious mental
illness. Psychiatr Serv 2016;67:275-81.
31. Cherner RA, Aubry T, Sylvestre J, et al. Housing first for adults with problematic substance use. J Dual Diagn 2017;13:219-29.
32. Goldfinger SM, Schutt RK, Tolomiczenko GS, et al. Housing placement and subsequent days homeless among formerly homeless adults with mental illness.
Psychiatr Serv 1999;50:674-9.
33. Hwang SW, Gogosis E, Chambers C, et al. Health status, quality of life, residential stability, substance use, and health care utilization among adults applying
to a supportive housing program. J Urban Health 2011;88:1076-90.
34. Lipton FR, Nutt S, Sabatini A. Housing the homeless mentally ill: a longitudinal
study of a treatment approach. Hosp Community Psychiatry 1988;39:40-5.
35. Martinez TE, Burt MR. Impact of permanent supportive housing on the use of
acute care health services by homeless adults. Psychiatr Serv 2006;57:992-9.
36. McHugo GJ, Bebout RR, Harris M, et al. A randomized controlled trial of integrated versus parallel housing services for homeless adults with severe mental
illness. Schizophr Bull 2004;30:969-82.
37. Rich AR, Clark C. Gender differences in response to homelessness services. Eval
Program Plann 2005;28:69-81. doi: 10.1016/j.evalprogplan.2004.05.003.
38. Sadowski LS, Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among
chronically ill homeless adults: a randomized trial. JAMA 2009;301:1771-8.
39. Siegel CE, Samuels J, Tang D-I, et al. Tenant outcomes in supported housing
and community residences in New York City. Psychiatr Serv 2006;57:982-91.
40. Stefancic A, Tsemberis S. Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: a four-year study of housing access
and retention. J Prim Prev 2007;28:265-79.
41. Stergiopoulos V, Hwang SW, Gozdzik A, et al.; At Home/Chez Soi Investigators.
Effect of scattered-site housing using rent supplements and intensive case
management on housing stability among homeless adults with mental illness:
a randomized trial. JAMA 2015;313:905-15.
42. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm
reduction for homeless individuals with a dual diagnosis. Am J Public Health
43. Young MS, Clark C, Moore K, et al. Comparing two service delivery models for
homeless individuals with complex behavioral health needs: preliminary data
from two SAMHSA treatment for homeless studies. J Dual Diagn 2009;5:
44. Kozloff N, Adair CE, Palma Lazgare LI, et al. “Housing First” for homeless youth
with mental illness. Pediatrics 2016;138:e20161514.
45. Gulcur L, Stefancic A, Shinn M, et al. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in
continuum of care and housing first programmes. J Community Appl Soc Psychol 2003;13:171-86. doi: 10.1002/casp.723.
46. Poremski D, Stergiopoulos V, Braithwaite E, et al. Effects of Housing First on
employment and income of homeless individuals: results of a randomized
trial. Psychiatr Serv 2016;67:603-9.
47. Booshehri LG, Dugan J, Patel F, et al. Trauma-informed Temporary Assistance
for Needy Families (TANF): a randomized controlled trial with a twogeneration impact. J Child Fam Stud 2018;27:1594-604.
ISSUE 10 E251
48. Ferguson KM. Employment outcomes from a randomized controlled trial of
two employment interventions with homeless youth. J Soc Social Work Res
49. Forchuk C, MacClure SK, Van Beers M, et al. Developing and testing an intervention
to prevent homelessness among individuals discharged from psychiatric wards to
shelters and “No Fixed Address”. J Psychiatr Ment Health Nurs 2008;15:569-75.
50. Gubits D, Shinn M, Wood M, et al. What interventions work best for families
who experience homelessness? Impact estimates from the family options
study. J Policy Anal Manage 2018;37:735-66.
51. Hurlburt MS, Hough RL, Wood PA. Effects of substance abuse on housing stability
of homeless mentally Ill persons in supported housing. Psychiatr Serv
52. Kashner TM, Rosenheck R, Campinell AB, et al. Impact of work therapy on
health status among homeless, substance-dependent veterans: a randomized
controlled trial. Arch Gen Psychiatry 2002;59:938-44.
53. Pankratz C, Nelson G, Morrison M. A quasi-experimental evaluation of rent
assistance for individuals experiencing chronic homelessness. J Community
Psychol 2017;45:1065-79. doi: 10.1002/jcop.21911.
54. Poremski D, Distasio J, Hwang SW, et al. Employment and income of people
who experience mental illness and homelessness in a large Canadian sample.
Can J Psychiatry 2015;60:379-85.
55. Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of supported
housing for homeless persons with mental illness. Arch Gen Psychiatry 2003;
56. Wolitski RJ, Kidder DP, Pals SL, et al.; Housing and Health Study Team. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav
57. Conrad KJ, Hultman CI, Pope AR, et al. Case managed residential care for
homeless addicted veterans. Results of a true experiment. Med Care 1998;
58. Graham-Jones S, Reilly S, Gaulton E. Tackling the needs of the homeless: a controlled trial of health advocacy. Health Soc Care Community 2004;12:221-32.
59. Lapham SC, Hall M, Skipper BJ. Homelessness and substance use among alcohol
abusers following participation in project H&ART. J Addict Dis 1995;14:41-55.
60. Nyamathi A, Flaskerud JH, Leake B, et al. Evaluating the impact of peer, nurse
case-managed, and standard HIV risk-reduction programs on psychosocial
and health-promoting behavioral outcomes among homeless women. Res
Nurs Health 2001;24:410-22.
61. Nyamathi AM, Zhang S, Salem BE, et al. A randomized clinical trial of tailored
interventions for health promotion and recidivism reduction among homeless
parolees: outcomes and cost analysis. J Exp Criminol 2016;12:49-74.
62. Sosin MR, Bruni M, Reidy M. Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago.
J Addict Dis 1995;14:1-20.
63. Towe VL, Wiewel EW, Zhong Y, et al. A randomized controlled trial of a rapid rehousing intervention for homeless persons living with HIV/AIDS: impact on
housing and HIV medical outcomes. AIDS Behav 2019;23:2315-25.
64. Upshur C, Weinreb L, Bharel M, et al. A randomized control trial of a chronic
care intervention for homeless women with alcohol use problems. J Subst
Abuse Treat 2015;51:19-29.
65. Weinreb L, Upshur CC, Fletcher-Blake D, et al. Managing depression among
homeless mothers: pilot testing an adapted collaborative care intervention.
Prim Care Companion CNS Disord 2016;18.
66. Clarke GN, Herinckx HA, Kinney RF, et al. Psychiatric hospitalizations, arrests,
emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs.
usual care. Ment Health Serv Res 2000;2:155-64.
67. Essock SM, Frisman LK, Kontos NJ. Cost-effectiveness of assertive community
treatment teams. Am J Orthopsychiatry 1998;68:179-90.
68. Essock SM, Mueser KT, Drake RE, et al. Comparison of ACT and standard case
management for delivering integrated treatment for co-occurring disorders.
Psychiatr Serv 2006;57:185-96.
69. Fletcher TD, Cunningham JL, Calsyn RJ, et al. Evaluation of treatment programs for dual disorder individuals: modeling longitudinal and mediation
effects. Adm Policy Ment Health 2008;35:319-36.
70. Lehman AF, Dixon LB, Kernan E, et al. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 1997;54:1038-43.
71. Morse GA, Calsyn RJ, Allen G, et al. Experimental comparison of the effects of
three treatment programs for homeless mentally ill people. Hosp Community
72. Morse GA, Calsyn RJ, Klinkenberg WD, et al. An experimental comparison of
three types of case management for homeless mentally ill persons. Psychiatr
73. Morse GA, Calsyn RJ, Klinkenberg WD, et al. Treating homeless clients with
severe mental illness and substance use disorders: costs and outcomes. Community Ment Health J 2006;42:377-404.
74. Braucht GN, Reichardt CS, Geissler LJ, et al. Effective services for homeless
substance abusers. J Addict Dis 1995;14:87-109.
75. Burnam MA, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults.
J Addict Dis 1995;14:111-34.
76. Cauce AM, Morgan CJ, Wagner V, et al. Effectiveness of intensive case management for homeless adolescents: rof a 3-month follow-up. J Emot Behav Disord
77. Clark C, Rich AR. Outcomes of homeless adults with mental illness in a housing
program and in case management only. Psychiatr Serv 2003;54:78-83.
78. Cox GB, Walker RD, Freng SA, et al. Outcome of a controlled trial of the effectiveness of intensive case management for chronic public inebriates. J Stud
79. Felton CJ, Stastny P, Shern DL, et al. Consumers as peer specialists on intensive case management teams: impact on client outcomes. Psychiatr Serv 1995;
80. Grace M, Gill PR. Improving outcomes for unemployed and homeless young
people: findings of the YP4 clinical controlled trial of joined up case management. Aust Soc Work 2014;67:419-37.
81. Korr WS, Joseph A. Housing the homeless mentally ill: Findings from Chicago.
J Soc Serv Res 1996;21:53-68.
82. Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: a randomized
controlled trial. Psychol Addict Behav 2017;31:231-41.
83. Marshall M, Lockwood A, Gath D. Social services case-management for longterm mental disorders: a randomised controlled trial. Lancet 1995;345:409-12.
84. Orwin RG, Sonnefeld LJ, Garrison-Mogren R, et al. Pitfalls in evaluating the
effectiveness of case management programs for homeless persons: lessons
from the NIAAA Community Demonstration Program. Eval Rev 1994;18:
85. Rosenblum A, Nuttbrock L, McQuistion H, et al. Medical outreach to homeless
substance users in New York City: preliminary results. Subst Use Misuse 2002;
86. Shern DL, Tsemberis S, Anthony W, et al. Serving street-dwelling individuals
with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical
trial. Am J Public Health 2000;90:1873-8.
87. Stahler GJ, Shipley TF Jr, Bartelt D, et al. Evaluating alternative treatments for
homeless substance-abusing men: outcomes and predictors of success.
J Addict Dis 1996;14:151-67.
88. Shumway M, Boccellari A, O’Brien K, et al. Cost-effectiveness of clinical case
management for ED frequent users: results of a randomized trial. Am J Emerg
89. Toro PA, Passero Rabideau JM, Bellavia CW, et al. Evaluating an intervention
for homeless persons: results of a field experiment. J Consult Clin Psychol
90. de Vet R, Beijersbergen MD, Jonker IE, et al. Critical time intervention for
homeless people making the transition to community living: a randomized
controlled trial. Am J Community Psychol 2017;60:175-86.
91. Herman DB, Conover S, Gorroochurn P, et al. Randomized trial of critical time
intervention to prevent homelessness after hospital discharge. Psychiatr Serv
92. Lako DAM, Beijersbergen MD, Jonker IE, et al. The effectiveness of critical time
intervention for abused women leaving women’s shelters: a randomized controlled trial. Int J Public Health 2018;63:513-23.
93. Shinn M, Samuels J, Fischer SN, et al. Longitudinal impact of a family critical
time intervention on children in high-risk families experiencing homelessness:
a randomized trial. Am J Community Psychol 2015;56:205-16.
94. Susser E, Valencia E, Conover S, et al. Preventing recurrent homelessness
among mentally ill men: a“ critical time” intervention after discharge from a
shelter. Am J Public Health 1997;87:256-62.
95. Samuels J, Fowler PJ, Ault-Brutus A, et al. Time-limited case management for
homeless mothers with mental health problems: effects on maternal mental
health. J Soc Social Work Res 2015;6:515-39.
96. Jones K, Colson PW, Holter MC, et al. Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatr
97. Tomita A, Herman DB. The impact of critical time intervention in reducing
psychiatric rehospitalization after hospital discharge. Psychiatr Serv 2012;63:
98. Jones K, Colson P, Valencia E, et al. A preliminary cost effectiveness analysis of
an intervention to reduce homelessness among the mentally ill. Psychiatr Q
99. Magwood O, Salvalaggio G, Beder M, et al. The effectiveness of substance use
interventions for homeless and vulnerably housed persons: a systematic
review of systematic reviews on supervised consumption facilities, managed
alcohol programs, and pharmacological agents for opioid use disorder. PLoS
ONE 15(1):e0227298. https://doi.org/10.1371/journal.pone.0227298.
100. Bahji A, Bajaj N. Opioids on trial: a systematic review of interventions for the
treatment and prevention of opioid overdose. Can J Addict 2018;9:26-33.
101. Clark N, Lintzeris N, Gijsbers A, et al. LAAM maintenance vs methadone maintenance for heroin dependence. Cochrane Database Syst Rev 2002;(2):CD002210.
102. Ferri M, Davoli M, Perucci CA. Heroin maintenance treatment for chronic
heroin-dependent individuals: a Cochrane systematic review of effectiveness.
J Subst Abuse Treat 2006;30:63-72.
103. Gowing L, Farrell MF, Bornemann R, et al. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev
104. Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioiddependent pregnant women: a comprehensive review. Addiction 2012;
105. Karki P, Shrestha R, Huedo-Medina TB, et al. The impact of methadone maintenance treatment on HIV risk behaviors among high-risk injection drug users:
a systematic review. Evid Based Med Public Health 2016;2:pii: e1229.
106. Kirchmayer U, Davoli M, Verster AD, et al. A systematic review on the efficacy of
naltrexone maintenance treatment in opioid dependence. Addiction 2002;97:
107. Larney S, Gowing L, Mattick RP, et al. A systematic review and meta-analysis of
naltrexone implants for the treatment of opioid dependence. Drug Alcohol Rev
108. Lobmaier P, Kornør H, Kunøe N, et al. Sustained-release naltrexone for opioid
dependence. Cochrane Database Syst Rev 2008;(2):CD006140.
109. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database
Syst Rev 2014;(2):CD002207.
110. Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus
no opioid replacement therapy for opioid dependence. Cochrane Database
Syst Rev 2009;(3):CD002209.
111. Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintenance treatment for
opioid dependence. Cochrane Database Syst Rev 2011;(4):CD001333.
112. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject
drugs. Cochrane Database Syst Rev 2017;9:CD012021.
113. Roozen HG, de Waart R, van der Windt DAWM, et al. A systematic review of the
effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence. Eur Neuropsychopharmacol 2006;16:311-23.
114. Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev
115. Simoens S, Matheson C, Bond C, et al. The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Br J
Gen Pract 2005;55:139-46.
116. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ
117. Helm S, Trescot AM, Colson J, et al. Opioid antagonists, partial agonists, and
agonists/antagonists: the role of office-based detoxification. Pain Physician
118. Strang J, Groshkova T, Uchtenhagen A, et al. Heroin on trial: systematic review
and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. Br J Psychiatry 2015;207:5-14.
119. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with
buprenorphine: assessing the evidence. Psychiatr Serv 2014;65:158-70.
120. Weinmann S, Kunstmann W, Rheinberger P. Methadone substitution — a scientific review in the context of out-patient therapy in Germany [article in German]. Z Arztl Fortbild Qualitatssich 2004;98:673-82.
121. Wilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation
in pregnant and postpartum women with opioid use disorder. Drug Alcohol
122. Klimas J, Gorfinkel L, Giacomuzzi SM, et al. Slow release oral morphine versus
methadone for the treatment of opioid use disorder. BMJ Open 2019;9:
123. Maglione MA, Raaen L, Chen C, et al. Effects of medication assisted treatment
(MAT) for opioid use disorder on functional outcomes: a systematic review.
J Subst Abuse Treat 2018;89:28-51.
124. Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes
associated with supervised drug consumption facilities: a systematic review.
Curr HIV/AIDS Rep 2017;14:161-83.
125. Potier C, Laprévote V, Dubois-Arber F, et al. Supervised injection services: what
has been demonstrated? A systematic literature review. Drug Alcohol Depend
126. McNeil R, Small W. ‘Safer environment interventions’: a qualitative synthesis of
the experiences and perceptions of people who inject drugs. Soc Sci Med
127. Muckle W, Muckle J, Welch V, et al. Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse.
Cochrane Database Syst Rev 2012;12:CD006747.
128. Ezard N, Dolan K, Baldry E, et al. Feasibility of a Managed Alcohol Program
(MAP) for Sydney’s homeless. Canberra (AU): Foundation for Alcohol Research
and Education; 2015.
129. Nielsen E, Novotna G, Berenyi R, et al. Harm reduction interventions for chronic
and severe alcohol use among populations experiencing homelessness: a literature review. Regina: University of Regina, Carmichael Outreach Inc.; 2018.
130. Basu A, Kee R, Buchanan D, et al. Comparative cost analysis of housing and
case management program for chronically ill homeless adults compared to
usual care. Health Serv Res 2012;47:523-43.
131. Culhane DP, Metraux S, Hadley T. Public service reductions associated with
placement of homeless persons with severe mental illness in supportive housing. Hous Policy Debate 2002;13:107-63.
132. Dickey B, Latimer E, Powers K, et al. Housing costs for adults who are mentally
ill and formerly homeless. J Ment Health Adm 1997;24:291-305.
133. Gilmer TP, Manning WG, Ettner SL. A cost analysis of San Diego County’s
REACH program for homeless persons. Psychiatr Serv 2009;60:445-50.
134. Gilmer TP, Stefancic A, Ettner SL, et al. Effect of full-service partnerships on
homelessness, use and costs of mental health services, and quality of life
among adults with serious mental illness. Arch Gen Psychiatry 2010;67:645-52.
135. Hunter S, Harvey M, Briscombe B, et al. Evaluation of housing for health permanent supportive housing program. Santa Monica (CA): RAND Corporation; 2017.
136. Holtgrave DR, Wolitski RJ, Pals SL, et al. Cost-utility analysis of the housing and
health intervention for homeless and unstably housed persons living with HIV.
AIDS Behav 2013;17:1626-31.
137. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use
and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009;301:1349-57.
138. Latimer EA, Rabouin D, Cao Z, et al.; At Home/Chez Soi Investigators. Costeffectiveness of Housing First intervention with intensive case management
compared with treatment as usual for homeless adults with mental illness:
secondary analysis of a randomized clinical trial. JAMA Netw Open 2019;
139. Lenz-Rashid S. Supportive housing program for homeless families: Foster care
outcomes and best practices. Child Youth Serv Rev 2017;79:558-63.
140. Lim S, Gao Q, Stazesky E, et al. Impact of a New York City supportive housing
program on Medicaid expenditure patterns among people with serious mental
illness and chronic homelessness. BMC Health Serv Res 2018;18:15.
141. McLaughlin TC. Using common themes: cost-effectiveness of permanent supported housing for people with mental illness. Res Soc Work Pract 2010;21:
142. Mares AS, Rosenheck RA. A comparison of treatment outcomes among chronically homelessness adults receiving comprehensive housing and health care
services versus usual local care. Adm Policy Ment Health 2011;38:459-75.
143. Pauley T, Gargaro J, Falode A, et al. Evaluation of an integrated cluster care
and supportive housing model for unstably housed persons using the shelter
system. Prof Case Manag 2016;21:34-42.
144. Schinka JA, Francis E, Hughes P, et al. Comparative outcomes and costs of
inpatient care and supportive housing for substance-dependent veterans. Psychiatr Serv 1998;49:946-50.
145. Srebnik D, Connor T, Sylla L. A pilot study of the impact of housing firstsupported housing for intensive users of medical hospitalization and sobering
services. Am J Public Health 2013;103:316-21.
146. Evans WN, Sullivan JX, Wallskog M. The impact of homelessness prevention
programs on homelessness. Science 2016;353:694-9.
ISSUE 10 E253
147. Clark RE, Teague GB, Ricketts SK, et al. Cost-effectiveness of assertive community treatment versus standard case management for persons with cooccurring severe mental illness and substance use disorders. Health Serv Res
148. Lehman AF, Dixon L, Hoch JS, et al. Cost-effectiveness of assertive community
treatment for homeless persons with severe mental illness. Br J Psychiatry
149. Wolff N, Helminiak TW, Morse GA, et al. Cost-effectiveness evaluation of three
approaches to case management for homeless mentally ill clients. Am J Psychiatry
150. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on
hospital service use among ED frequent users. Am J Emerg Med 2000;18:603-8.
151. Hwang SW. Homelessness in health. CMAJ 2001;164:229-33.
152. National Clinical Guideline Centre (UK). Patient experience in adult NHS services: improving the experience of care for people using adult NHS services —
patient experience in generic terms. NICE Clinical Guidelines No 138. London
(UK): Royal College of Physicians; 2012. Available: www.ncbi.nlm.nih.gov/
books/NBK115230 (accessed 2019 Dec. 12).
153. Jonker IE, Sijbrandij M, Van Luijtelaar MJA, et al. The effectiveness of interventions during and after residence in women’s shelters: a meta-analysis. Eur J
Public Health 2015;25:15-9.
154. Rivas C, Ramsay J, Sadowski L, et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of
women who experience intimate partner abuse. Cochrane Database Syst Rev
155. Speirs V, Johnson M, Jirojwong S. A systematic review of interventions for
homeless women. J Clin Nurs 2013;22:1080-93.
156. Wathen CN, MacMillan HL. Interventions for violence against women: scientific
review. JAMA 2003;289:589-600.
157. Constantino R, Kim Y, Crane PA. Effects of a social support intervention on
health outcomes in residents of a domestic violence shelter: a pilot study.
Issues Ment Health Nurs 2005;26:575-90.
158. Gubits D, Shinn M, Wood M, et al. Family options study: 3-year impacts of housing and services interventions for homeless families. 2016. doi: 10.2139/
159. Milby JB, Schumacher JE, Wallace D, et al. To house or not to house: the
effects of providing housing to homeless substance abusers in treatment. Am J
Public Health 2005;95:1259-65.
160. Nyamathi AM, Leake B, Flaskerud J, et al. Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color. Res Nurs
161. Nyamathi A, Flaskerud J, Keenan C, et al. Effectiveness of a specialized vs. traditional AIDS education program attended by homeless and drug-addicted
women alone or with supportive persons. AIDS Educ Prev 1998;10:433-46.
162. Wang JZ, Mott S, Magwood O, et al. The impact of interventions for youth
experiencing homelessness on housing, mental health, substance use, and
family cohesion: a systematic review. BMC Public Health 2019;19:1528.
163. Couch J. ‘My life just went zig zag’: refugee young people and homelessness.
Youth Stud Aust 2011;30:22-32.
164. Couch J. ‘Neither here nor there’: refugee young people and homelessness in
Australia. Child Youth Serv Rev 2017;74:1-7.
165. Couch J. On their own: perceptions of services by homeless young refugees.
Dev Pract 2012;(31):19-28.
166. D’Addario S, Hiebert D, Sherrell K. Restricted access: The role of social capital
in mitigating absolute homelessness among immigrants and refugees in the
GVRD. Refuge 2007;24:107-15.
167. Dwyer P, Brown D. Accommodating “others”?: housing dispersed, forced
migrants in the UK. J Soc Welf Fam Law 2008;30:203-18.
168. Flatau P, Smith J, Carson G, et al. The housing and homelessness journeys of refugees in Australia. AHURI Final Rep No 256. Melbourne (AU): Australian Housing and Urban Research Institute Limited; 2015.
169. Hulín M, Hulínová VA, Martinkovic M, et al. Housing among persons of international protection in the Slovak Republic. Rajagiri J Soc Dev 2013;5.
170. Idemudia ES, Williams JK, Wyatt GE. Migration challenges among Zimbabwean
refugees before, during and post arrival in South Africa. J Inj Violence Res
171. Im H. A social ecology of stress and coping among homeless refugee families.
Vol. 73, Dissertation Abstracts International Section A: Humanities and Social
Sciences. University of Minnesota Digital Conservancy; 2012:355. Available:
N&AN=2012-99130-061 (accessed 2019 Sept. 1). Login required to access
172. Kissoon P. From persecution to destitution: a snapshot of asylum seekers’
housing and settlement experiences in Canada and the United Kingdom.
J Immigr Refug Stud 2010;8:4-31.
173. Kissoon P. An uncertain home: refugee protection, illegal immigration status,
and their effects on migrants’ housing stability in Vancouver and Toronto. Can
174. Mostowska M. Migration and homelessness: the social networks of homeless
Poles in Oslo. J Ethn Migr Stud 2013;39:1125-40.
175. Mostowska M. Homelessness abroad: “place utility” in the narratives of the
Polish homeless in Brussels. Int Migr 2014;52:118-29.
176. Paradis E, Novac S, Sarty M, et al. Homelessness and housing among status
immigrant, non-status migrant, and Canadian-born Families in Toronto. Can
177. Sherrell K, D’Addario S, Hiebert D. On the outside looking in: the precarious
housing situations of successful refugee claimants in the GVRD. Refuge
178. Sjollema SD, Hordyk S, Walsh CA, et al. Found poetry: finding home — a qualitative study of homeless immigrant women. J Poetry Ther 2012;25:205-17.
179. Walsh CA, Hanley J, Ives N, et al. Exploring the experiences of newcomer
women with insecure housing in Montréal Canada. J Int Migr Integr 2016;17:
180. Kendall CE, Shoemaker ES, Crowe L, et al. Engagement of people with lived
experience in primary care research: living with HIV Innovation Team Community Scholar Program. Can Fam Physician 2017;63:730-1.
181. Swinkels H, Pottie K, Tugwell P, et al.; Canadian Collaboration for Immigrant
and Refugee Health (CCIRH). Development of guidelines for recently arrived
immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. CMAJ 2011;183:E928-32.
182. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction — GRADE
evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:
183. Pottie K, Mathew CM, Mendonca O, et al. PROTOCOL: A comprehensive review
of prioritized interventions to improve the health and wellbeing of persons
with lived experience of homelessness. Campbell Syst Rev 2019;15:e1048.
184. Magwood O, Gebremeskel A, Ymele Leki V, et al. Protocol 1: The experiences of
homeless and vulnerably housed persons around health and social services. A protocol for a systematic review of qualitative studies. Cochrane Methods Equity;
2018. Available: https://methods.cochrane.org/equity/sites/methods.cochrane.
2019 Dec. 12).
185. Kpade V, Magwood O, Salvalaggio G, et al. Protocol 3: Harm reduction and pharmacotherapeutic interventions for persons with substance use disorders: a protocol for a systematic review of reviews. Cochrane Methods Equity; 2018.
186. Wang J, Mott S, Mathew C, et al. Protocol: Impact of interventions for homeless
youth: a narrative review using health, social, Gender, and equity outcomes.
Cochrane Methods Equity; 2018. Available: https://methods.cochrane.org/
_review_protocol.pdf (accessed 2019 Dec. 12).
187. Alonso-Coello P, Oxman AD, Moberg J, et al.; GRADE Working Group. GRADE
Evidence to Decision (EtD) frameworks: a systematic and transparent
approach to making well informed healthcare choices. 2: Clinical practice
guidelines. BMJ 2016;353:i2089.
188. Alonso-Coello P, Schünemann HJ, Moberg J, et al.; GRADE Working Group.
GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent
approach to making well informed healthcare choices. 1: Introduction. BMJ
189. Schünemann HJ, Mustafa R, Brozek J, et al.; GRADE Working Group. GRADE
Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical
practice and public health. J Clin Epidemiol 2016;76:89-98.
190. GRADEpro GDT: GRADEpro Guideline Development Tool [software]. Hamilton
(ON): McMaster University; 2015 (developed by Evidence Prime, Inc.). Available: https://gradepro.org (accessed 2019 Feb. 1).
191. Tugwell P, Knottnerus JA. When does a good practice statement not justify an
evidence based guideline? J Clin Epidemiol 2015;68:477-9.
192. Guyatt GH, Alonso-Coello P, Schünemann HJ, et al. Guideline panels should
seldom make good practice statements: guidance from the GRADE Working
Group. J Clin Epidemiol 2016;80:3-7.
193. Guyatt GH, Schünemann HJ, Djulbegovic B, et al. Guideline panels should not
GRADE good practice statements. J Clin Epidemiol 2015;68:597-600.
194. Drazen JM, de Leeuw PW, Laine C, et al. Toward more uniform conflict disclosures:
the updated ICMJE conflict of interest reporting form. JAMA 2010;304:212-3.
195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid
publishing conflict and a proposed agreement for co-author teams [editorial].
Biol Conserv 2014;176:277-80.
196. WHO housing and health guidelines. Geneva: World Health Organization; 2018.
197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary
care: PEER simplified guideline. Can Fam Physician 2019;65:321-30.
198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in
Substance Misuse. Management of opioid use disorders: a national clinical
practice guideline. CMAJ 2018;190:E247-57.
199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56.
200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8.
201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www.
homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12).
202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone.
Can Fam Physician 2018;64:170-2.
203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National
Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content
/uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1).
Competing interests: Gary Bloch is a founding member, former board
member and currently a clinician with Inner City Health Associates
(ICHA), a group of physicians working with individuals experiencing
homelessness in Toronto, which provided funding for the development
of this guideline. He did not receive payment for work on the guideline
and did not participate in any ICHA board decision-making relevant to
this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive
payment for any aspect of the submitted work. No other competing interests were declared.
This article has been peer reviewed.
Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie,
d Wendy Muckle led
the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance
use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic
led the review on income, David Ponka and Eric Agbata led the review
on case management, Jean Zhuo Jing Wang and Sebastian Mott led the
homeless youth review, Harneel Kaur led the homeless migrant review,
Christine Mathew and Anne Andermann led the homeless women
review, Syeda Shanza Hashmi and Ammar Saad led medical student
engagement and competency review, Thomas Piggott co-led the GRADE
Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and
Nicole Kozloff contributed substantially to the substance use review,
and Neil Arya and Stephen Hwang provided critical policy information.
All of the named authors engaged in the writing and review, gave final
approval of the version of the guideline to be published, and agreed to
be accountable for all aspects of the work.
Funding: This guideline was supported by a peer-reviewed grant from
the Inner City Health Associates, and supplemental project grants from
the Public Health Agency of Canada, Employment Social Development
Canada, Canadian Medical Association and Champlain Local Integrated
Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the
guideline. The funders had no role in the design or conduct of the study;
collection, analysis and interpretation of the data; or preparation,
review or final approval of the guideline. Final decisions regarding the
protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee.
Acknowledgements: The authors thank everyone who participated in
the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members.
Endorsements: Canadian Medical Association, Canadian Public Health
Association, Canadian Federation of Medical Students, The College of
Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to
End Homelessness, Canadian Nurses Association
Disclaimer: The views expressed herein do not necessarily represent
the views of the funding agencies.
Correspondence to: Kevin Pottie, email@example.com
The Lancet Countdown on Health and Climate Change
Policy brief for Canada
1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the
448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the
Recommendation: Incorporate lessons learned from recent severe wildfire seasons
into a strengthened pan-Canadian emergency response approach that anticipates
increasing impacts as the climate continues to change.
Finding: The percentage of fossil fuels powering transport in Canada remains high, though
electricity and biofuels are gaining ground. Fine particulate air pollution generated by
transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.
Recommendation: Develop provincial and territorial legislation requiring automakers to
gradually increase the annual percentage of new light-duty vehicles sold that are zero
emissions, working toward a target of 100% by 2040.
Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in
the world, with healthcare accounting for approximately 4% of the country’s total emissions.
Recommendation: Establish a sustainable healthcare initiative that assembles experts from
research, education, clinical practice, and policy to support Canada’s healthcare sector in
reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with
healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement,
charting a course for zero-emissions healthcare by 2050.
Finding: The health of Canadians is at risk due to multiple and varied risks of climate
change, including those described in this policy brief (see Figure 1). An ongoing,
coordinated, consistent and pan-Canadian effort to track, report, and create healthy
change is required.
Recommendation: Integrate health considerations into climate-related policymaking
across sectors, including in Canada’s updated 2020 Nationally Determined Contribution
Commitments under the United Nations Framework Convention on Climate Change
(UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share
in achieving the goals of the Paris Agreement.
Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2
“The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era
will come to define the health of an entire generation.”3
However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the
climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path.
Key messages and recommendations
Health and climate change in Canada
Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in
Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie
Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples
outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least
1.5oC as compared to a 1986-2005 reference period.4
Two scenarios are possible for the remainder of the child’s life.
If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as
the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to
1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of
wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as
undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety
and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within
populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This
degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2
Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6),
temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving
Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada
Indicators of climate-related health impacts
This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional
recommendations can also be found in the 2017 and 2018 policy briefs.6,24
Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in
2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more
than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures
not only pose a threat to public health, but also result in major economic and social burdens.
2019 marks a crux point for humanity: choices and policies made in
the lead up to the 2020 UNFCCC Nationally Determined Contribution
submissions will determine whether the world follows the disastrous
high-emissions scenario, or the safer low-emissions path. Children
are taking to the streets to demand a livable world. It is the task of
today’s political leaders and other adults to exert maximal effort
within their spheres of influence in order to set a course for a
healthy response to climate change.
public transit, cycling and walking rates, and adhering to a plantrich
diet in accordance with Canada’s new food guide,
decrease emissions, and also improve health and decrease
Canada is not on track: in 2016, total Canadian GHG emissions were
704 Mt CO2e, an increase of more than 100 Mt since 1990.31
Policies and measures currently under development but not yet
implemented are forecast to reduce national emissions to 592 Mt
CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513
32—a goal which is itself too weak to represent a fair
contribution by Canada to the emissions reductions necessary to
meet the goals of the Paris Climate Change Agreement.
The Earth as a whole is warming less quickly than Canada—but still
far too fast. The IPCC and the World Health Organization have
emphasized that keeping global surface temperature warming to
1.5oC is key to obtaining the best outcomes now possible for human
health.33,34 To do so would require global net human-caused
emissions to fall by about 45% from 2010 by 2030, reaching ‘net
zero’ by 2050.34 Updated Nationally Determined Contributions to
the Paris Agreement are due to be submitted by 2020: policymakers
must integrate health considerations through proposed
Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.*
Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission)
*N.B. Reporting for 2017 only includes evacuations up to and including July
In a mid-range GHG emissions scenario, wildfires in Canada are
projected to rise 75% rise by the end of the 21st century,36
necessitating a strong adaptive response. Human health impacts of
fire include death, trauma, and major burns,37 anxiety during
wildfire periods,35,38 and post-traumatic stress disorder, anxiety
and depression related to evacuations.39,40 Wildfire smoke also
travels vast distances41 and increases asthma and chronic
obstructive pulmonary disease exacerbations, with growing evidence
of an association with all-cause mortality.41 Impacts on health
systems can be severe: during the Fort McMurray fire hospital staff
evacuated 103 patients in a matter of hours,10,42 and the 2017 British
Columbia wildfires resulted in 700+ staff displaced, 880 patients
evacuated, and 19 sites closed by the Interior Health Authority, at a
cost of $2.7 million.12 Such devastating events also generate
significant emissions, contributing to climate change, and helping to
generate conditions conducive to future blazes.43
Much can be done to lessen the health impacts of wildfires.
Qualitative data indicates that populations who are better-briefed
on the local evacuation plan, as well as ways to lessen the risk of fire
to their property, are not only more prepared but also less
anxious.35,38 Building codes can be changed to help keep smoke out,
primary care practitioners can ensure vulnerable patients receive
at-home air filtration systems and respiratory medications prior to
wildfire season,44 public health professionals can collaborate with
municipal officials to maximize smoke forecast-informed outdoor
and well-ventilated indoor recreation opportunities,38 and health
personnel can help ensure evacuation plans are clearly
Sustainable and healthy transport
since 2000, they account for less than 4% of the energy used in
transport (Figure 3). This rate of change is inconsistent with the
emissions pathway required to keep today’s and future children
Support is therefore required for investments in public transit,47
and cycling infrastructure,48 creating win-wins for health by
increasing physical activity levels and improving community
cohesion, while reducing chronic disease, healthcare costs and
GHG emissions.49,50 Zero emissions vehicles also reduce air pollution
and are increasingly affordable: the up-front cost of electric vehicles
is forecast to become competitive on an un-subsidized basis from
2024 onwards.51 British Columbia recently passed legislation
requiring all new cars sold to be zero-emission by 2040.52 Other
provinces would benefit from matching this ambition.
Figure 3: Per Capita Fuel Consumption for Transport in Canada.
Source: Lancet Countdown
Transport-related pollution is harming the health of Canadians. Fine
particulate matter (PM2.5) air pollution related to land-based
transportation was responsible for approximately 1063 deaths in
2015 in Canada, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.24 Additionally,
Canada has the highest pediatric asthma rate amongst countries of
comparable income level, with nitrogen dioxide (NO2) from traffic
responsible for approximately 1 in 5 new cases of asthma in
With transport responsible for 24% of national GHG emissions in
2017,31 decarbonizing this sector must be prioritized. Progress is
entirely too slow: total fuel consumption for road transport per
capita decreased 5.4% from 2013 to 2016. While per capita
use of electricity and biofuels for transport increased by 600%
Healthcare sector emissions
Though Canadians are proud of the care they provide for one another
with this country’s system of universal healthcare,53 Lancet Countdown
analysis reveals an area which should give pause to all who endeavor to
“do no harm”: Canada’s healthcare system has the world’s third highest
emissions per capita.
Previous analysis showed healthcare sector emissions to be responsible
for 4.6% of the national total,54 as well as more than 200,000 tons of
other pollutants, resulting in 23,000 disability-adjusted life years (DALYs)
lost annually.54 Emissions from the health sector represent a strategic
mitigation target in a single-payer healthcare system straining under
the weight of an inexorably increasing burden of disease.
While Canadian healthcare sector emissions are increasing, the
world-leading Sustainable Development Unit in England reported an
18.5% decrease in National Health Service, public health and social
care system emissions from 2007-2017 despite an increase in clinical
Despite healthcare being a provincial jurisdiction, there is a role for
pan-Canadian sustainability initiatives to unite diverse experts
spanning public health and the spectrum of clinical disciplines,
economics, sustainability science and beyond. This demands health
sector-wide education, consistent with existing efforts to increase
environmental literacy for health professionals.56
1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the
health effects of climate change: Lancet and University College London
Institute for Global Health Commission. Lancet 2009;373(9676):1693-733.
2. Watts N, Amann M, Arnell N, et al. The 2018 report of The Lancet
Countdown on health and climate change: shaping the health of nations
for centuries to come. Lancet 2018; vol. 392: 2479–514.
3. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet
Countdown on health and climate change: ensuring that the health of a
child born today is not defined by a changing climate. Lancet 2019; vol.
4. Government of Canada. Canada’s Changing Climate Ottawa, Ontario,; 2019.
5. Government of the Northwest Territories. Climate Observations in the Northwest
Territories (1957-2012) Inuvik * Norman Wells * Yellowknife * Fort Smith.
6. Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for
Canadian Policymakers. Lancet Countdown and Canadian Public Health Association;
2017 October 31st, 2017.
7. Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food
on nutrient intake among Inuit in Arctic Canada: impact of climate change
and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127.
8. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate
change-related loss. Nature Climate Change 2018;8:275-81.
9. Yao J, Eyamie J, Henderson SB. Evaluation of a spatially resolved forest fire
smoke model for population-based epidemiologic exposure assessment. J
Expo Sci Environ Epidemiol 2016;26(3):233-40.
10. Hampshire G. Hospital heroes get patients to safety during Fort McMurray fire:
17 buses took 105 patients to safety in dramatic evacuation. CBC News. 2016.
Available from: http://www.cbc.ca/news/canada/edmonton/hospital-heroesget-
11. Kirchmeier-Young M, Zwiers F, Gillett N, Cannon A. Attributing extreme fire risk
in Western Canada to human emissions. Climatic Change 2017;144(2):365-79.
12. British Columbia Interior Health Authority. Wildfire Emergency Response
13. Kirchmeier-Young M, Gillett N, Zwieres F, Cannon A, Anslow F. Attribution of
the Influence of Human-Induced Climate Change on an Extreme Fire Season.
Earth’s Future: American Geophysical Union 2018.
14. Alberta Health. Impact of Wildfires on the Mental Health of Fort McMurray
Residents: Neurotic Disorders, Daily Physician Visits within an Emergency
Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and
Performance Division, Analytics and Performance Reporting Branch,; 2016.
15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation
of the 2013 Alberta flood from weather and climate perspectives. Climate
16. Canadian Broadcasting Corporation. Alberta Flood 2013: The five people we
lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/
17. United Nurses of Alberta. UNA Calgary office closed, many health facilities
affected by southern Alberta flooding. 2013 June 21, 2013.
18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change,
Drought and Human Health in Canada. Int J Environ Res Public Health
19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of
Drought on the Canadian Prairies. EcoHealth 2004.
20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate
Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http://
21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare
for farmers. 2018. Available from: https://www.theglobeandmail.com/
22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al.
Temper-ature-related changes in airborne allergenic pollen abundance and
seasonality across the northern hemisphere: a retrospective data analysis.
Lancet Planet Health 2019;3(3):e124-e31.
23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin
K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017.
Canadian Communicable Disease Review 2018;44(10):231-6.
24. Howard C, Rose C, Rivers N. Lancet Countdown 2018 Report: Briefing for
Canadian Policymakers. Canadian Medical Association, Canadian Public
Health Association, The Lancet Countdown; 2018 November.
25. a. Regional Public Health Department of Montreal. Epidemiological
Investigation Heat Wave Summer 2018 in Montréal - Summary. 2019.
b. Vogel MM, Zscheischler J, Wartenburger R, et al. Concurrent 2018 hot
extremes across Northern hemisphere due to human-induced climate
change. Earth's Future, 2019; vol. 7, 692–703. https://doi.org/10.1029/
26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019
Sept 20, 2019]; Available from: http://projects.upei.ca/climate/2014/02/16/
27. Kelleya C, Mohtadib S, Canec M, Seagerc R, Kushnirc Y. Climate change in the
Fertile Crescent and implications of the recent Syrian drought. Proceedings
of the National Academy of Science 2015;112 no 11: 3241–6,.
28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal
pathways framework. Int J Public Health 2010;55(2):123-32.
29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural
synergies: climate change policy and health equity. Bull World Health Organ
30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health
and climate change: policy responses to protect public health. Lancet
31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.];
Available from: https://www.canada.ca/en/environment-climate-change/
32. Environment and Climate Change Canada. Canadian Environmental Sustainability
Indicators: Progress Towards Canada’s Greenhouse Gas Emissions
Reduction Target. 2019 [Sept 3, 2019]; Available from: https://www.canada.
33. Ebi K, Campbell-Lendrum D, Wyns A. The 1.5 Health Report--Synthesis on
Health and Climate Science in the IPCC SR1.5. 2018 2018.
34. Intergovernmental Panel on Climate Change. Global Warming of 1.5C--Summary
for Policymakers. 2018 October 8, 2018.
35. Christianson A. Wildland Fire Evacuations in Canada. Natural Resources
36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire
37. Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et
al. Black Saturday: the immediate impact of the February 2009 bushfires in
Victoria, Australia. Med J Aust 2009;191(1):11-6.
38. Dodd W, Scott P, Howard C, Scott C, Rose C, Cunsolo A, et al. Lived experience
of a record wildfire season in the Northwest Territories, Canada. Can J Public
39. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder
and general psychopathology in children and adolescents following a wildfire
disaster. Can J Psychiatry 2005;50(3):137-43.
40. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress
following wildfires disaster in a rural part of Greece: a case-control population-
based study. Int J Emerg Ment Health 2011;13(1):11-26.
41. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical Review
of Health Impacts of Wildfire Smoke Exposure. Environ Health Perspect
42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery
management of healthcare services. J Bus Contin Emer Plan 2017;11(2):128-
43. Liu Y, Goodrick S, Heilman W. Wildland fire emissions, carbon, and climate:
Wildfire–climate interactions. Forest Ecology and Management 2014;317:80-
44. Barn PK, Elliott CT, Allen RW, Kosatsky T, Rideout K, Henderson SB. Portable air
cleaners should be at the forefront of the public health response to landscape
fire smoke. Environ Health 2016;15(1):116.
45. Maguet S. Public Health Responses to Wildfire Smoke Events. BC Center for
Disease Control; 2018.
46. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban
burdens of paediatric asthma incidence attributable to ambient NO2 pollution:
estimates from global datasets. Lancet Planet Health 2019;3(4):e166-e78.
47. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet
physical activity recommendations. Am J Prev Med 2005;29(4):273-80.
48. United Kingdom Department of Transport. Value for Money Assessment for
Cycling Grants. 2014.
49. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects
of the London bicycle sharing system: health impact modelling study. BMJ
50. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits
and transportation-related reductions in greenhouse gas emissions in the San
Francisco Bay area. Am J Public Health 2013;103(4):703-9.
51. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al.
Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from
sustainable food systems. Lancet 2019.
52. Zussman R. Legislation introduced to require all new cars sold in B.C. to be
zero-emission by 2040. Global News Online. 2019. Available from: https://
53. Thompson N. More Canadians take pride in symbols of the country’s present
than its past: survey. 2019.
54. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions
and health damages from the Canadian healthcare system: An economic-
environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623.
55. National Health System Sustainable Development Unit. Reducing the use of
natural resources in health and social care 2018 report. 2018.
56. Parkes M, Poland B, Allison A, Cole DC, Culbert I, Gislason MK, et al. In
press-Preparing for the future of public health: Ecological determinants of
health and the call for an eco-social approach to public health education.
Canadian Journal of Public Health 2019. DOI: 10.17269/s41997-019-00263-8.
Organisations and acknowledgements
The concept of this brief was developed by the Lancet Countdown on Health
and Climate Change.
This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose,
PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD.
Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman,
Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD;
Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their
Contributions and review on behalf of the Lancet Countdown were provided
by Jess Beagley and Nick Watts, MBBS.
THE LANCET COUNTDOWN
The Lancet Countdown: Tracking Progress on Health and Climate Change is an
international, multi-disciplinary collaboration that exists to monitor the links
between public health and climate change. It brings together 35 academic
institutions and UN agencies from every continent, drawing on the expertise
of climate scientists, engineers, economists, political scientists, public health
professionals, and doctors. Each year, the Lancet Countdown publishes an
annual assessment of the state of climate change and human health, seeking
to provide decision-makers with access to high-quality evidence-based
policy guidance. For the full 2019 assessment, visit www.lancet
THE CANADIAN MEDICAL ASSOCIATION
The Canadian Medical Association (CMA), formed in Quebec City in 1867,
has led some of Canada’s most important health policy changes. As we
look to the future, the CMA will focus on advocating for a healthy population
and a vibrant profession.
THE CANADIAN PUBLIC HEALTH ASSOCIATION
The Canadian Public Health Association (CPHA) is a national, independent,
non-governmental organization that advances public health education,
research, policy and practice in Canada and around the world through the
Canadian Journal of Public Health, position statements, discussion
documents and other resources.
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device.
Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available.
The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs.
To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2
The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here.
The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field.
* Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted.
* A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements.
* All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged.
* Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach.
* Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed.
* Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction.
* Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages.
* The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient.
* Storing images and data on a smart-device should be limited as much as possible for data protection purposes.
* Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device.
* All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices.
* Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated.
4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions.
5. AUDIT & RETENTION
* It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests.
* Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary.
* Original photos should be retained and not overwritten.
* All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level.
* It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention.
* Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album.
* It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification.
* At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration.
* Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs.
* If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach.
* In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary.
Approved by the CMA Board of Directors March 2018
i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡
† University of Calgary, Canada
‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada
1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4.
2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.