FUNDING THE CONTINUUM OF CARE
The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom.
After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services.
Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA.
By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria.
Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services.
Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment.
First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12
There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions.
The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding.
* Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living;
* home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences;
* there should be quality and accreditation standards for both public and private service delivery;
* there should be uniform approaches to needs assessment for home care and long-term care;
* there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component;
* there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage;
* there should be recognition and financial support for informal care givers;
* there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage;
* there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and
* provision should be made for pre-funding long-term care from public and private sources.
Prevention and Health Promotion
The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians.
One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations.
The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level.
The CMA recommends that:
the federal government continue funding of the national immunization strategy consistent with the original three-year funding program;
governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and
the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level.
Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket.
The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income.
In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion.
The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15
Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16
Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories).
Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions.
The CMA recommends that:
governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies;
such a program should include the following elements:
* a mandate for all Canadians to have either private or public coverage for prescription drugs;
* a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income);
* FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both;
* group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and,
* a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs);
the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective;
the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies;
the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans;
governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and
the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program.
Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18
According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21
In light of the foregoing, the CMA believes that:
optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status;
the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation;
support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community;
strategies should be implemented to reduce wait times for accessing publicly funded home and community care services;
integrated service delivery systems should be created for home and community care services; and
any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion.
The CMA recommends that:
governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;"
governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care;
governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and
governments undertake pilot studies to support informal caregivers and long-term care patients, including those that:
a) explore tax credits and/or direct compensation to compensate informal caregivers for their work,
b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations,
c) expand income and asset testing for residents requiring assisted living and long-term care, and
d) promote information on advance directives and representation agreements for patients.
Mental Health Care
In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24
The CMA recommends that:
the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act;
in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and
Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research.
According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26
The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27
A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28.
This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care.
Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund.
A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs.
The federal government has several options available to promote the pre-funding of long-term care:
Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance.
Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care.
Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29.
Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta.
In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity.
The CMA recommends that:
governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and
the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited.
The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31
The CMA recommends that:
governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care.
1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools.
1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957.
2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970.
3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984.
4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964.
5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008.
6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997.
7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002.
8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002.
9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09.
10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08.
11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08.
12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007.
13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003.
14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08.
15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09.
16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB.
17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
18 Service Canada. Employment insurance (EI) compassionate care benefits. http://18.104.22.168/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09.
19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007.
20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42.
21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15.
22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000.
23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006.
24 Canadian Healthcare Association. September 2009.
25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005.
26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006.
27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007.
28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009.
29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09.
30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09.
31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
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—
The Patient’s Medical Home 2019
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.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 13
14 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
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—
The Patient’s Medical Home 2019 15
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—
The Patient’s Medical Home 2019
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
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 17
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—
The Patient’s Medical Home 2019
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—
The Patient’s Medical Home 2019 19
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—
The Patient’s Medical Home 2019
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.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 21
22 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
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—
The Patient’s Medical Home 2019 23
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—
The Patient’s Medical Home 2019
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.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 25
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—
The Patient’s Medical Home 2019
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 27
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—
The Patient’s Medical Home 2019
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
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 28
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.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 29
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—
The Patient’s Medical Home 2019
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
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 31
32 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
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—
The Patient’s Medical Home 2019 33
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.
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMA Primary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to health care for all Canadians.
The first part of the wait time continuum that can be measured is when the patient schedules his or her first visit ith a family physician. A family physician may then refer the patient to specialty care. Both of these stages in the continuum have not been addressed in wait time discussions thus far. The available evidence suggests that one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist.
Thus, there are three main issues around our focus on primary care wait times:
Access to primary care for those without a family physician;
Access to primary care for those with a family physician; and
Referral from primary to more highly specialized care.
The CFPC has proposed a target that 95% of Canadians in each community have a family physician by 2012. There are two ways to achieve this goal: 1. increase the number of family physicians practicing in Canada and 2. increase the capacity of existing family physicians. To help address the supply issue, medical schools must find innovative ways to encourage more medical students to choose family medicine. A second approach to increasing the supply of family physicians is to provide more training opportunities so that qualified International Medical Graduates can be integrated into the family physician workforce. In terms of capacity, there are a number of approaches that have been taken to help improve family physicians' ability to take on additional patients. For example, financial incentives geared towards this objective have been included in some physician contracts. However, much more can be done in this regard, such as improving patient flow with more efficient practice management procedures
There are several models for primary care delivery operating in Canada, including various collaborative practice arrangements with different care providers working together. However, thus far there is no conclusive evidence that any one particular model is better than all of the others in terms of providing timely access to care. Many studies have compared various models in a variety of ways; each with different conclusions. While there is no definitive research on best models for primary care delivery, there is a range of innovative approaches to enhancing timely access to quality primary medical care. More research is necessary to help determine which model or models of primary care, if broadly implemented, will make considerable improvements to patient access.
Aside from collaborative care practice models, we must look for solutions that increase patient access to care through enhanced practice efficiency and not by expecting family physicians to work harder and longer. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To address this, enhanced practice management training should be provided during medical school education and residency levels and Continuing Medical Education programs should be created.
One method of improving practice efficiency is through a process known as Clinical Practice Redesign (CPR). The main objective CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. This undertaking requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. These efforts can go a long way to help improve patient access and increase capacity to accommodate patient appointments.
One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous undertaking given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness.
Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind.
When a patient is referred to more highly specialized care, a concerted effort must be made to keep the lines of communication as open as is feasible between family physicians and consulting specialists, in both directions. Improved communication between providers is essential to improving the wait time at this point in the continuum.
While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care can be a greater challenge in rural locations. Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access.
When considering the concept of target-setting, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians and referrals to other specialists. Furthermore, it must be acknowledged that regardless of how targets are determined, even if they are met, not everyone will receive care within the most appropriate period of time for their particular situation.
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMAPrimary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to primary care for Canadians.
The Partnership released its interim report, ... And Still Waiting: Exploring Primary Care Wait Times in Canada, in April 2008 to stimulate discussion and
agreement about ways to improve timely access to primary care and from primary to more highly specialized care. It reviewed a broad range of issues faced by family doctors in a health system that has largely ignored the wait time challenges their patients face and was very well received by members of the CMA, CFPC and other stakeholders. This final report is a focused approach to some of the recommendations and solutions, especially of relevance in primary medical care.
The difficulty in measuring primary care wait times for myriad illnesses and conditions was identified in the first report as one that may impede progress in finding solutions to the wait time challenges that family doctors experience. The PCWTP believes that the initial requirement is the ability to measure and track wait times along the continuum of the patient's care but that this capacity in primary as well as more highly specialized levels of care is still very limited. There is also the need to prioritize which benchmarks or targets should be attained along the patient's wait time continuum: 1) to find a family physician; 2) to be seen by a family physician; and 3) to have a diagnostic intervention or to be seen by a consulting specialist.
The difficulty in measuring primary care wait times for myriad illnesses and conditions...may impede progress in finding solutions to the wait time challenges that family doctors experience.
Methodology and Scope of Report
This paper is an opportunity to draw attention to issues of relevance to family physicians and their patients waiting for care - either to find a family doctor, or to be seen by their family doctor or to be seen by another specialist. The paper is a reflection of several data sources, including:
Expert opinion from family physician leaders in practice and research
The National Physician Survey (NPS) results from 2004 and 2007
Given the available expertise within the PCWTP representing two national medical organizations that advocate for patients in primary care and for the resources that support high quality care, the authors of this paper are in a unique position to use their knowledge and understanding to contribute to the proposed solutions and recommendations.
It is easier to define what is in than what is out of scope for this paper. There is a variety of important influences coming to bear on primary care wait times. Some are beyond the scope of this discussion. For example, the health system is promoting more collaborative care and while this is an increasingly important part of practice, its influence on primary care wait times has yet to be determined.
There are also enablers and impediments to improved access to care, some of these still poorly defined. For example, where a physician practices and the influence of location, e.g. suburban in contrast to rural communities, makes a difference to access. The location of resources based on criteria such as cost-effectiveness and skill maintenance requires more attention. Likewise, new models of primary care are encouraging incentives to practice differently. But it is still uncertain how these new models of care are affecting access to timely care.
Finally, there are many personal factors that affect patient choice and physician decision in determining when access is acceptable or when it is intolerable. Risk plays an important part in these decisions but not all risk is measurable. Some experts have also suggested not every waiting list is a bad list. These issues require much more analysis than this paper allows.
In short, recommendations for further research will be reinforced as much by what we know as by what we still do not know.
What Does It Mean?
In the first report by the PCWTP, primary care was defined as first-contact medical care and services provided by family physicians and general practitioners. In contrast, primary health care was defined as the broader determinants of health, including health services delivered by other professional providers. Likewise, in that report it was acknowledged that "primary care is the foundation and family physicians are the backbone of the health system as the first points of contact for most patients." Patients have access to a continuum of medical services by first presenting to their family physician at the primary care level.
Individuals may require specialty care at various points in their lives. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care.
(Figure 1) [SEE PDF FOR CORRECT DISPLAY]
What does it mean to have a family physician? As set out in the CFPC's Four Principles of Family Medicine, a person may be said to have a family physician when they have established a patient-physician relationship that provides for continuing care through repeated contacts across the life cycle and in which the physician becomes an advocate for the patient by referring to other specialists and other health care resources as appropriate. While in the past this relationship has often been established through an unwritten contract, in some of the new practice models patients are formally "rostered", that is to say they sign a commitment to seek all of their non-emergent care from the particular physician or clinic.
Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care.
What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them.
The largest population-based surveys that collect data on health care use among the general population have been conducted by Statistics Canada. They have not asked specifically about "family physicians" but rather about "regular doctors" or "regular medical doctor". In its 2007 Canadian Community Health Survey (CCHS), Statistics Canada asked the simple question, Do you have a regular medical doctor?1 Nationally, 85% of the population aged 12 or older reported that they did. In 2008, the CFPC commissioned a Harris/Decima survey and found that 86% of respondents had a family physician. 2 The CFPC proposed a target that 95% of Canadians in each community have a family physician by 2012. Some regions of the country may be close to attaining this target while others have far to go.
Persons with a regular doctor are more likely to report greater continuity of care. According to Statistics Canada's 2007 Survey of Experiences with Primary Health Care, among the 86% of the population reported to have a regular medical doctor, 95% said that they would either definitely or probably be taken care of by the same physician or nurse each time they visited their physician's office. In contrast, among the 10% of the population with no regular doctor but some regular place of care, just 31% said they would definitely or probably see the same physician or nurse with each visit. 3
What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. These are referred to as unattached (or orphaned) patients. They obtain episodic care from places like walk-in clinics and hospital emergency rooms (ERs). A recent report by the Institute for Clinical Evaluative Sciences (ICES) found that there are significant excess visits to ERs among people with chronic conditions who do not have a regular family physician. 4 Reducing the number of unattached patients could therefore have a substantial impact on the problem of overcrowded ERs.
Of the estimated 4.1 million Canadians aged 12 and over who indicated that they did not have a regular doctor in the 2007 CCHS, 78% reported that they had some other usual source of care. Among these individuals, the most frequently cited source of care was walk-in clinics (64%), followed by hospital emergency rooms (12%), community health centres (10%) and "other" (14%). 5
The Concept of the Medical Home
For those with a family physician there has been an increase in the literature in the United States on the concept of a "medical home". In 2007 the American Academy of Family Physicians and three other medical associations adopted "joint principles of the patient-centered medical home" that include:
-each patient having a personal physician
-physician directed medical practice
-whole person orientation
-coordinated care across all elements of the health system
-quality and safety (e.g. support for optimal patient-centered outcomes)
-enhanced access to care (e.g. open appointment scheduling); and
-appropriate payment incentives. 6
The Commonwealth Fund attempted to assess the proportion of patients with a medical home in their 2007 International Health Policy Survey. Their definition included patients that have "a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care (yes)." While 84% of Canadian respondents on the survey reported that they had a doctor that they usually see (consistent with all other survey estimates), just under one out of two (48%) were considered to have a medical home according to the Commonwealth Fund definition. Of the seven countries surveyed, respondents in New Zealand and Australia were the most likely to be considered as having a medical home (61% and 59% respectively). 7
Primary Care Models
There are several models for primary care delivery and thus far there is no conclusive evidence that any one particular model is better than all of the others. Many studies have compared various models in a variety of ways; each with different conclusions. For example, a comprehensive comparative study on the productive efficiencies of four models of primary care delivery in Ontario concluded that no one type of model dominates and that further research is required. 8
Furthermore, another study comparing various primary health care models with regard to a number of variables including access and quality came to the same conclusion. It found that the fee-for-service physician practice model ranked highest in terms of patient access and responsiveness, while community health centres ranked highest in effectiveness, productivity, continuity and quality. 9
Finally, another study that compared patient satisfaction in walk-in clinics, ERs and family practices came to the conclusion that in terms of waiting time, patients were most satisfied with family practices. 10
While there is no definitive research on best models for primary care delivery, this report shows there is a range of innovative approaches to enhancing timely access to quality primary medical care.
The issue of wait times has dominated the health policy agenda in Canada, particularly since the First Ministers Accord in 2004. Prior to that however, in their February 2003 Accord, which they considered to be a "covenant", governments agreed to develop and report on common indicators. Among the 40 indicators listed in the 2003 Accord, in addition to access to primary care (measured as a percentage of the population with a regular family doctor and a percentage of doctors accepting new patients), the list included seven wait-time/volume indicators, of which the following were pertinent to primary care:
-referral to specialists for cancers (lung, prostate, breast, colo-rectal), heart and stroke;
-diagnostic tests (MRI, CT); and
-proportion of services/facilities linked to a centralized (provincial/regional) wait list management system for selected cancers and surgeries, referral to specialists, emergency rooms and diagnostic tests. (11)
These commitments were overtaken, however, by the 2004 Accord which called for evidence-based benchmarks for five procedures including cancer, heart, diagnostic imaging, joint replacements and sight restoration. (12) National benchmarks were achieved in December 2005, but they begin from the point where the decision has been reached on treatment between the consulting specialist and patient. (13)
A. To Family Medicine
In discussions regarding the total time patients wait for care, what is often overlooked is the fact that the wait time continuum starts when a patient has a medical problem. However, the first part of the continuum that can be measured is when the patient schedules his or her first visit with a family physician. Figure 2 below illustrates the full wait time continuum.
[figure 2. SEE PDF]
Access to a family physician is a major concern in this country. In a series of focus groups conducted by Ipsos-Reid across Canada in 2007 on behalf of the CMA, the following concerns/issues were raised by some patients:
-people had been searching for a family physician for several years without success;
-people with a family physician were frightened about the prospect of their doctor retiring; and
-people with a family physician reporting waits of three or four weeks to get an appointment.(14)
According to the Commonwealth Fund survey in 2007, Canada had the lowest rate of same-day physician appointments by a wide margin. 22% of respondents said they could see their physician on the same day, versus 30% in the US and 41% and higher for the remaining five countries. Canada also had the highest rate of respondents noting it took six or more days to see their physician, at 30%, as opposed to 20% for Germany and the US and lower for the other four
countries surveyed (7). However, in the 2007 National Physician Survey (NPS), 65% of family physicians stated that their patients with urgent needs are able to see them within one day. For non-urgent cases, 41% are able to see their patients within one week and 66% are able to see their non-urgent patients within four weeks.(15)
In the 2007 Health Council of Canada survey, of the 26% of respondents who stated they require routine or ongoing care, 45% noted that they had to wait too long for an appointment and 29% said it was difficult to get an appointment. 16 Furthermore, according to the 2007 NPS, when other specialists were asked to rate their patients' access to family physicians, only 13% gave it a very good or excellent rating, while over half (55%) gave it a fair or poor rating.
This survey also found that 86% of family physicians stated they had made arrangements for care for their patients outside of their normal office hours. When asked to list the arrangements they have in place, one third (33%) said they extend their office hours, over one third (37%) operate an after-hours clinic that is staffed by members of their practice and 41% included calling a 24/7 telehealth phone line as an option. However, over half (52%) included going to an ER as one of these arrangements.(15)
The aforementioned surveys have shown there is evidence of a disparity between patients' and physicians' perspectives regarding access to primary care. Moreover, Canada lags behind other countries in access to primary care.
B. To Specialty Care
The next stage of the wait time continuum is also often overlooked. This is when a family physician refers the patient to specialty care. The Fraser Institute's research on patient wait times does take this into account, however. According to their most recent survey, the average wait time between referral by a family physician and a consulting specialist fell from 9.2 weeks in 2007 to 8.5 weeks in 2008.(17) It is encouraging to see some movement in the right direction, but there is much more room for improvement. According to the 2007 NPS, only one quarter (24%) of family physicians rated patient access to other specialists as very good or excellent, while over one third (36%) of family physicians rated patient access to other specialists as fair or poor. 15 Some specialists will not take phone calls from family physicians - the only method of communication is by fax, which makes it difficult for the family physician to confirm whether the consulting specialist has received the referral and acted on it.
Efforts must be made to keep the lines of both communication and access as open as is feasible between family physicians and consulting specialists, in both directions. Other specialists have noted having some difficulty scheduling appointments for their patients with their family physicians after consultation and/or treatment.
The Canadian Medical Protective Association (CMPA) has identified a specific process for referring physicians to follow and includes the following guidance: When a patient is referred to a consulting specialist, the family physician should provide sufficient clinical information so that the consultant can appropriately prioritize his or her referrals. The consultant should notify the family physician of the patient's scheduled appointment. If the timing of this appointment does not seem reasonable to the family physician, he or she should then attempt to schedule an earlier appointment. If this is not possible, the family physician should consider alternative options to seek specialty care and discuss these with the patient. The patient should also be informed of what to expect if his or her condition changes while waiting for specialty care, and what to do and who to consult if this occurs. 18 The Collaborative Action Committee on Intra-professionalism (CACI) was established in 2006 by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada to discuss enhancing intra-professionalism and exploring ways to encourage desired behaviours that will improve physicians' intra-professional relationships. This work is vital to ensure a seamless continuum of care for patients between family physicians and other specialists. Working groups have been established to focus on improving relations through medical education, training and accreditation and in practice by developing enhancements to the referral-consultation process. (19)
Should a timely referral not be available, the CMPA's latest guidance on wait times in a September 2007 information sheet addresses the issue of liability when health-care resources such as specialty care are limited. The sheet notes that physicians may be requested to provide care outside their area of expertise when resources are scarce. While noting that the courts have yet to address this issue, it suggests the "courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be evaluated in light of what a reasonable and prudent physician like you would have decided in similar circumstances". 20 Nonetheless, given that the decision to refer implies that a physician has determined that a problem is beyond his or her scope of practice, the issue of support for the physician managing what might be long waits for specialty care will need to be addressed.
An additional barrier to timely patient access to specialty care is the inconsistency in family physicians' abilities to order advanced diagnostic tests. The Canadian Association of Radiologists (CAR) has guidelines for all physicians to follow when ordering diagnostic tests.
C. Rural Versus Urban Access
While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care is often considered a greater challenge in rural locations. The 2007 NPS survey found that this is not the case. In fact, the opposite is true. There is very little difference in same-day family physician access rates between urban and rural locations and with regard to other specialties, the difference between urban and rural physicians is notable, with 51% of rural physicians stating that urgent appointments can be made on the same day as opposed to only 37% of urban physicians.
However, there is a difference between rural and urban settings with regard to factors that increase demand on a physician's time. For example, the 2007 NPS found a lack of availability of other specialists locally was a more significant factor for rural physicians (65%) than for urban (55%), as was the lack of other health care professionals, which was a concern for 66% of rural physicians in contrast to 54% for urban physicians. This survey shows that health human resources is a concern for all physicians, especially in rural settings. (15)
It should be pointed out that rural and urban physicians' differing perceptions about access for their patients may have an effect on survey findings; the weather and distance to travel to obtain specialty care, for example, affect a rural family physician's view of the quality of access.
The 2007 NPS found that access to Routine andAdvanced Diagnostics was rated very similarly by rural and urban physicians of all specialties, with access to routine services rated higher than access to advanced services in all respects. When the physician's specialty is taken into account, both rural and urban family physicians rated access to routine diagnostics higher than other specialists (very good or excellent - 48% versus 37%). The reverse is true for access to advanced diagnostics, with 15% of family physicians rating it very good or excellent, whereas 21% of other specialists gave it these rankings. (15)
Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. The most commonly regarded solution to the problem of access to specialty care in rural regions is to increase the number of specialty services in that area; for many specialties, however, this may not be feasible due to insufficient numbers of patients residing in the area to support an effective workload.
Next Steps - Finding Solutions
For the purposes of this paper, "target" is defined as a time-based standard for accessing care.
A. Measuring Primary Care Wait Times
What primary care wait times should be measured? How can they be measured? While the selection of the five priority areas noted earlier has stimulated progress in the measurement of waiting for treatment once the consulting specialist has been seen, as the Fraser Institute has reported for the past two years, nationally one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. In 2008 the Institute estimated the average total wait from referral to treatment at 17.3 weeks; of this the wait from referral to specialty consultation was estimated at 8.5 weeks - 49% of the total (17).
Among the recent provincial/territorial initiatives there has been no systematic effort to capture the time from family physician referral to specialty consultation. For its part, the Wait Time Alliance is launching a project in spring 2009 that will record the actual total waiting time from initial referral to treatment among a sample of consulting specialists and their patients.
B. Setting Targets
For the purposes of this paper, "target" is defined as a time-based standard for accessing care. This may be further graduated by the urgency for which the care is needed, and it may also be qualified by a percentage threshold of attainment. For example, "90% of patients with the least urgent requirement for care will be seen within one month of referral".
When considering the concept of target-setting, two important points must be stressed:
- before any reasonable wait time targets can be established, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians, appointments and referral to other specialists; and
- regardless of how the targets are determined, even if the targets are met, not everyone will receive care within the most appropriate period of time for their particular situation.
Targets to Accessing Primary Care
There are two key considerations in this paper with regard to targeting wait times in access to primary care. While other jurisdictions and researchers have considered other approaches, e.g. wait times to access a primary care setting, this paper is focused on ways to improve timely access to primary medical care for those Canadians who have their own family physician and for those who do not - as well as timely access to specialty care services from their family physician.
Finding a Family Physician
What would it take to reach the target of 95% of Canadians in each community having a family physician by 2012? An estimated 4.1 million Canadians aged 12 or older do not have a family physician. Statistics Canada further subdivides the 4.1 million into those who have not looked for a family physician (2.4 million) and those who have looked but cannot find one (1.7 million) (1). A telephone survey conducted by Harris/Decima in October and November 2008 found that of the 14% of respondents who do not have a family physician, 61% were not looking for a family physician for themselves or a family member. 45% of these stated they are not looking for one because they go to a walk-in clinic or an ER instead, whereas the other half were not looking because they presumed no family physicians were available.(2)
It would seem reasonable that the population who has looked for but cannot find a family physician should be a priority target to advancing toward the 2012 goal. As advocated and explored by the CFPC, this may entail establishing registries for unattached patients in communities across Canada. Several provinces and territories have included incentives in their physician contracts for taking on unattached patients and it would be useful to assess their effectiveness.
One way to increase the number of family physicians practicing in Canada is to encourage more medical students to choose family medicine by exposing them to family practices early on and to obtain placements in practices that are keenly interested in demonstrating the benefits of family practice to medical students. Support for family practice preceptors and teachers is also important. Incentives to attract more preceptors are required and facilities should be created to improve medical students' awareness of these opportunities across the country.
Ontario has set a target of finding a family physician for 500,000 unattached patients over the next three years. 21 Ontario already has in place an incentive schedule for patients in its primary care models to take on new patients. The most common of these models (i.e. with the largest number of physicians participating) is the Family Health Group, which provides a payment of $100 each for up to 50 newly enrolled patients without a family physician per year with a premium of 10% for patients aged 65-74 and 20% for those aged 75 and over. There is also a payment of $150 for rostering unattached patients discharged from an inpatient hospital stay. Effective April 1, 2009 a complex/vulnerable new patient fee of $350 will also be introduced, with criteria still under development.
New Brunswick has a pilot project in place that is based on a $150 premium, payable in addition to fee-for-service (FFS) billings in installments of $50 per visit up to the maximum. In the Yukon, family physicians who accept unattached patients are paid $200 over and above the initial visit fee.
95% of Canadians in each community should have their own family physician by 2012
Another option currently being discussed in a number of jurisdictions is to allow faster integration of qualified International Medical Graduates (IMGs) by evaluating the equivalency of family medicine training and qualification programs done in other countries. In order to increase the number of family physicians who are trained to provide high-quality care, the CFPC recently approved the following initiatives:
-Expansion of the Alternative Route to Certification for practicing FPs interested in Certification in Family Medicine (practice eligible) to those who have been practicing for at least five years in Canada.
-Granting Certification to family physicians who hold Certification with the American Board of Family Medicine (ABFM), are in good standing with the American Academy of Family Physicians and are moving to Canada.
-Evaluate other postgraduate family medicine training and certification programs in jurisdictions outside Canada in order to consider granting reciprocity for family physicians with training and certification equivalent to family medicine programs in Canada.
Access to Family Physicians
In terms of targeting approaches to the time to get an appointment to see the family physician, it would appear that the "evidence-based" approaches of urgency scoring will be impractical because they require an assessment of the patient. It may be worth investigating the methodology used by the provincial health phone lines to triage patients based on the use of structured algorithms and exploring whether this can be used in a primary care physician office to better gauge the level of each patient's need to see their physician and to organize the physician's patient schedule in a more effective manner. This would require additional resources (both staff and technology) be made available to the family physician's practice.
Want to learn more?
Capital Health in Halifax is exploring "a program of supports for family physicians and family practice nurses working in fee-for-service practices in Nova Scotia: www.cfpc.ca/nursinginfamilypracticeTQVI
When considering approaches to address the issue of increasing access for patients with a family physician, we must look for solutions that do so through enhanced practice efficiency and not by expecting family physicians to work longer.
Improving practice efficiencies can be accomplished through enhanced practice management training during medical school education and residency levels. Continuing Medical Education programs on this topic will also be beneficial. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To encourage interest in this aspect of running a medical practice it is important that they are made aware of all of the benefits of a well-managed office (e.g. more time spent doing direct patient care, the ability to increase patient load and attain a better work-life balance).
New Approaches to Practice Management
Some progress is being made to enhance Canadians' access to primary care. A variety of projects are underway that have already shown improvements in this area, including a number of successful efforts occurring in British Columbia, Alberta and Saskatchewan that include the implementation of a innovative practice management system known as Advanced Access. The term Clinical Practice Redesign (CPR) is becoming a more popular description of the process involved.
"Advanced Access is about reengineering clinic practices so that patients can see a physician or other primary care practitioner at a time and date that is convenient for them. The advanced access model is often considered to be another scheduling system; however, it is in fact a comprehensive approach to effective patient care delivery."(22)
The main objective of CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. The main premise is that if patient demand for appointments is overall in balance with the physician capacity to schedule appointments, it should be possible to offer patients an appointment on the same day that they telephone for one. The challenge is to work down the backlog and achieve that balance. Once this is accomplished, the wait time to see the physician can be dramatically reduced.
The originators of this concept have identified six steps in implementing CPR:
1. Measure and balance supply and demand
2. Eliminate the accumulated backlog
3. Reduce the number of appointment types
4. Develop contingency plans (e.g., flu season)
5. Reduce and shape demand (e.g., phone and e-mail for answering questions)
6. Increase effective supply by delegating tasks 23
Want to learn more?
Family Physician Dr. Ernst Schuster presents advanced access in family practices through the Alberta Access Improvement Measures (AIM): www.cfpc.ca/advancedaccessTQVI
The sentinel indicator that is used to monitor CPR is what is termed "third next available appointment" and is defined as the average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment.
Another common patient scheduling technique, often misinterpreted as Advanced Access, is more accurately referred to as the "carve out" model. It involves keeping a block of time open each day for patients who call that day for an urgent appointment. While it allows patients with an urgent problem to see their family physician the same day, it could potentially make the wait time for non-urgent problems longer as there are fewer appointment times that can be used for those cases. It is nonetheless a step in the right direction and shows that family physicians are making efforts to alleviate the primary care access problem.
CPR is gaining momentum as a popular method of improving practice efficiency. The first group practice to adopt this system in Saskatchewan was able to reduce its average wait time from 17 days to just two. (24) In addition to reducing wait times, many practices in British Columbia, Alberta and Saskatchewan have been able to increase their patient load due to efficiency improvements. This is therefore also addressing the concern about the large number of Canadians who do not have a family physician.
The United Kingdom Experience
The UK has adopted fixed targets for primary care, irrespective of the patient's presenting condition. The 2004 National Health Service (NHS) Improvement Plan set out a 24/48 hour access target, by which UK patients would be guaranteed the opportunity of seeing a primary care provider within 24 hours and a GP within 48 hours. (25) The UK has since adopted an incentive approach to achieving this target through an Improved Access Scheme. First implemented on a voluntary basis in 2007, some 5 million surveys were sent to GPs' patients across England about their recent experience with access to their GP. The survey results are linked to a reward payment that has four elements:
- 48 hour target reward element;
- advance booking target reward element;
- ease of telephone access target reward element; and
- preferred health care professional target reward element.
The level of payment for each element is linked to the satisfaction level reported by the patients. (26)
The survey has now been successfully administered twice. In 2008, almost two million responses were received - a 41% response rate. Key findings from the 2008 survey include the following:
- 87% of patients reported that they were satisfied with their ability to get through to their doctor's surgery on the phone.
- 87% of patients who tried to get a quick appointment with a GP said they were able to do so within 48 hours.
- 77% of patients who wanted to book ahead for an appointment with a doctor reported that they were able to do so.
- 88% of patients who wanted an appointment with a particular doctor at their GP surgery reported that they could do this. (27)
Any kind of patient-based reporting on access requires an up-to-date electronic roster of patients. The survey tool used in the UK is very simple and can be completed online. It should be noted however that the cost of the 2007 survey was estimated at £11 million although this also includes the patient choice survey. (28)
No doubt less complex approaches could be developed for applying an incentive approach to reach targets in Canada. However, this would involve the types of supports and resources available to general practitioners in the UK. In addition, the views of the public and patients should be sought before adopting any targeting approaches in primary care. This was emphasized by Berta et al in a Canadian public opinion study of the importance of ten measures of primary care performance. They found that the most important factors for patients were related to the family physicians' knowledge and skills, while the access indicators were least important. (29)
Targets to Accessing Specialty Care
One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous challenge given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. National and international experience would suggest that there have been two broad approaches:
- the development of "condition-specific" approaches to target-setting linked to a clinical assessment of urgency; and
- the adoption of targets that apply to all conditions that are progressively shortened as they are achieved.
Since the early 1990s, the NHS has made remarkable progress in tackling wait times through the adoption of targets that have been gradually shortened. This began with the first UK patient charter that was adopted in 1991. Reflecting the long waiting lists at that time, it included the right, "to be guaranteed admission for treatment by a specific date within two years". (30) In 1995 a second version of the Patient Charter lowered this period to 18 months, and to one year for coronary artery bypass grafts. (31) In the late 1990s the NHS moved from the Charter to a series of national service frameworks for conditions such as heart disease and cancer. These frameworks evolved into shortened targets. For example in 2001 the target was a maximum one month wait from diagnosis to first treatment for breast cancer by the end of 2001, in 2005 this was extended to all cancers by December 2005. 32 The most recent development has been the 2004 commitment that by the end of 2008 no patient will have to wait longer than 18 weeks from GP referral to hospital treatment.(33) The UK is on track to meet this target, but it must be emphasized that this has been achieved through a combination of a large infusion of resources, plus policy changes such as the shift from block funding to Payment by Results that reimburses hospitals on the basis of the number of patients treated. It should also be emphasized that the NHS is a much more integrated system than Canada's health care system, and it would be more challenging to define accountability for reaching wait time targets.
Past Work on Improving Specialty Care Access
In Canada, the "gold standard" of target-setting is considered to be the work done by Naylor and colleagues in developing the urgency rankings for coronary revascularization procedures that underpin the Cardiac Care Network (CCN) of Ontario. This was done using a modified version of the techniques developed by the RAND Corporation in the 1980s to establish appropriateness guidelines for various procedures. In this work a panel of cardiologists and cardiac surgeons rated 438 fictitious case-histories on a seven-point scale of maximum acceptable waiting time for surgery. A regression model was then used to derive a scoring system based on the regression coefficients attached to the major determinants of urgency. (34) This system was implemented to prioritize waitlists by CCN which now works with 18 cardiac care centres in Ontario.
A group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests.
The Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists.
In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters.
Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation.
In the late 1990s a similar approach was used by the Western Canada Waiting List (WCWL) Project to develop priority scoring tools for cataract surgery, general surgery, hip and knee replacement, MRIs and children's mental health. (35) The tool for hip and knee replacement has been adapted for use by family physicians to determine priority of referral to orthopaedic surgeons,although to date it has only been tested on simulated paper cases.(36) The Saskatchewan Surgical network has applied the WCWL approach to develop scoring tools in 12 procedural areas. (37) Clearly it would be a large undertaking to adopt all these tools for use in primary care and to develop tools for the numerous areas that have yet to be tackled. Thus far, governments have concentrated, for the most part, on their initial five priorities. In the Fall of 2007 the Wait Time Alliance added five new benchmark areas, including emergency care, psychiatric care, plastic surgery, gastroenterology and anesthesiology (pain management) and it has challenged governments to adopt them. (38)
Recent Efforts to Improve Specialty Care Access
How can we work to achieve these targets? There are a variety of initiatives underway to expedite the referral and consultation process. In 2006, the CFPC and the Royal College of Physicians and Surgeons of Canada said that three steps could improve the referral and consultation process:
- a defined single access point within local referral/consultation systems;
- templates for referrals and consultations advice;
- an agreement amoung key players (relevant GP/FP and other specialty organizations) on referral/consultation criteria."(39)
As an example, a group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. This process has been very successful in reducing the need for repeat appointments. This practice also implemented a policy that the patient is referred to the first available urologist rather than to a specific physician. This new pooled referral system has reduced patient wait times remarkably and has been very well received by all parties. (40) In addition, other specialties in that province have shown interest in introducing a similar system in their practices.
As an additional example of simple ways to gain efficiencies, the Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. (41)
In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters.
Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care (BGSC) - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation.
This pilot project is intended to address priority areas, including:
- mental health: anxiety and depression
- lower back pain management
- lower gi endoscopy
- orthopaedics: arthroplasty
- plastic surgery: carpal tunnel, breast reconstruction, breast reduction and skin lesions
- lung cancer (42)
One of the objectives of this pilot project is to establish guaranteed time frames from referral to consulting specialist in the specific practice areas and to offer alternative options to patients who may exceed these time lines. The BGSC software includes primary care pathways and an electronic referral process, allowing family physicians to send all necessary referral information, such as primary care workups, treatments and testing results, to the other specialist offices electronically. These specialists can then respond to the referrals electronically, advising family physician offices of referral acceptance, appointment dates and times and any additional information within days of receiving the referral request.
Want to learn more? Ms. Brie DeMone offers an overview of the government of Manitoba's project to improve communication and coordination between family physicians and other specialists. "Bridging General and Specialist Care" and "the Catalogue of Specialized Services". www.cfpc.ca/BGSCTQVI
In January 2009, the web-based Catalogue of Specialized Services (CSS) was launched, which, is, according to provincial director of patient access Dr. Luis Oppenheimer, "like a catalogue order entry system. If you're a GP/FP looking for a service, you will get a catalogue of who provides that service, [...] some idea of the waiting time or capacity for that service [...] and have immediate confirmation of whether [your request] is accepted." By clearly providing family physicians and their offices with information on "who does what", referrals can be accurately directed to the right specialist at the right time, saving time and effort for the family physician, other specialist and patient (42),(43).
A third new initiative currently underway in Manitoba, the Patient Access Registry Tool (PART), will provide other specialists with the clinical information they need to manage patient demand. Patient demographics and provider information as well as a diagnosis and planned interventions will be available through this tool and it will also document several key wait time dates, including when a referral was first received, the date of the first specialist consultation and when a patient is ready for treatment. Once it is fully operational, PART will capture information on all patients needing a medical consultation or surgery in Manitoba. (44)
British Columbia offers a Full Service Family Practice Program with a broad range of incentives
The Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension
Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. Currently there is simply not enough information available to establish reasonable wait time targets. The ability to accurately measure and monitor access at all points along the care continuum will require a significant investment in information infrastructure and this system must be in place and used effectively before targets are developed. More importantly, this cannot be effectively implemented without coordinated support from all governments. The Manitoba Government is a pioneer with this particular effort and their pilot projects will be closely monitored for effectiveness.
C. Remuneration Models
Since the early 1990s there has been a steadily declining trend in fee-forservice (FFS) as the sole mode of payment for family physicians. In 1990, the CMA's Physician Resource Questionnaire (PRQ) survey results showed that 71% of family physicians received 90% or more of their professional income from FFS.45 Subsequent PRQ surveys showed successive decreases and on the 2007 NPS, fewer than one out of two (48%) family physicians reported receiving 90% or more of their income from FFS. 15 While the majority of physicians continue to receive some income from FFS, increasingly it is being blended with other remuneration methods.
A blended payment model known as the Family Health Network is now available in Ontario. In this model, capitation accounts for about 65% of a family physician's remuneration. The remainder consists of fee-for-service and other incentive payments and premiums.
Over the past decade there has been an international trend towards the adoption of "pay-for-performance" (P4P), in which a variety of payment incentives are used to promote certain physician behaviours. To date, these incentives have been used mainly to encourage process improvements in the delivery of care. The earliest forms of P4P focused on prevention screening, but more recently they have expanded to address chronic disease management. P4P generally works by linking a bonus payment to the achievement of a specific performance target in the patient population. In its new primary care models, Ontario provides bonus payments for cancer prevention screening and diabetes management, as well as other incentives for activities including palliative care and care for patients with serious mental illness. (46)
Similarly, British Columbia offers a Full Service Family Practice Program with a broad range of incentives. (47) The recently concluded Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension.(48)
As previously noted, several jurisdictions also provide incentives to acquire new patients. Internationally the UK has gone further by providing a bonus to the attainment of timely access targets as reported by patients. However, the UK also has a long-established rostering system and it has a much less geographically dispersed population than does Canada. Nonetheless it might be interesting to assess the potential for incentives to enhance access to primary and specialty care in Canada.
D. Electronic Medical Records
Regardless of how a wait time management strategy might be implemented (e.g., at the level of the province, health region, hospital) it will be critical to be able to capture and monitor referral data electronically, starting with the family physician. It may be seen in Table 1 below that according to the 2007 National Physician Survey, there remains a large gap in this regard. Nationally almost two out of three family physicians (63%) continue to use paper charts as their method of record keeping. One out of five (19%) uses a combination of electronic and paper charts while just over one out of 10 (12%) report using electronic charts instead of paper charts.Across the country there is more than two-fold variation of those using paper charts ranging from a low of 36% inAlberta to a high of 81% in PEI and Quebec.
[TABLE 1. SEE PDF]
Internationally, the Commonwealth Fund has shown that Canada lags far behind comparator countries in the uptake of electronic medical records (EMRs). On its 2006 survey of primary care physicians in seven countries, fewer than one out of four (23%) Canadian respondents reported that they used EMRs in their offices compared to nine out of ten in the UK, New Zealand and the Netherlands.(49)
Aside from the issues of wait times for those patients with a family physician there is also the challenge of capturing information about access to primary medical care for those without their own family physician.
E. Practice Support
Improvements in access to family physicians can also be accomplished through the addition of staff support, of which there are two types:
1 clinical practice support(ie nurse or MOA for patient care),and
2 change management practice support (those with knowledge of clinical practice redesign to support physicians in making, monitoring and sustaining change).
The Practice Support Program in British Columbia offers training and financial incentives for family physicians working with medical office assistants and in one district health authority in Nova Scotia, a project is underway where family physicians can obtain financial support to employ family practice nurses through enhanced fee-for-service billings. At present, however, widespread deployment of practice support personnel is constrained by rules of fee-for-service payment that require the physician to have direct contact with each patient for whom a service is billed to the provincial or territorial medicare plan.
In terms of change management practice support, thus far CPR has had limited uptake in the rest of the country, primarily due to a lack of awareness. However, stories of the successes with this program are now being heard in the rest of the country and it is increasing in popularity. For example, a new Advanced Access initiative has been recently introduced in Manitoba through their Ministry of Health. In Nova Scotia, one practice that has had great success with Advanced Access is managed by the 2008 recipients of the Health Care Provider of the Year Award in Cape Breton, Elaine Rankin and Steven MacDougall. They worked together on an Advanced Access research project beginning in 2006. Once Dr. MacDougall cleared his patient wait list, he began to operate a same day access practice where his patients can call in the morning for an appointment that day. Now, the number of non-urgent patients from his practice who go to the emergency department has dropped by 28%. 50 By all accounts, those who have implemented CPR indicate they would never return to the traditional model where the appointment schedule is full before the work day starts.
CPR is not a tool to be used exclusively in family practices. The group urology practice in Saskatchewan that introduced the notion of pooled referrals with much success has also been engaged in the process of CPR since early 2007. Their practice is now beginning to enjoy the fruits of their labour through reduced wait times for patients who are referred to their practice. The "champion" of this undertaking, Dr. Visvanathan, noted that Clinical Practice Redesign involves improving practice work flow, the introduction of Electronic Medical Records and getting the right staff to do the right jobs. (40)
The implementation of a more efficient practice management system such as CPR requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. Experience to date suggests that these efforts pay off in terms of improved patient access and increased capacity to accommodate patient appointments.
There are three main issues that should concern our focus on primary care wait times:
- Access to primary care for those without a family physician;
- Access to primary care for those with a family physician; and
- Referral from primary to more highly specialized care.
There are general recommendations that would help address these issues and other recommendations that are more specific to each. This paper has provided valuable information that supports the following recommendations.
As noted in the introduction to this paper, it is difficult to measure primary care wait times for myriad illnesses and conditions, and this difficulty may impede progress in finding solutions to the wait time challenges that family doctors experience. The Primary Care Wait Time Partnership (PCWTP) believes that the ability to measure and track wait times along the full continuum of the patient's care is of utmost importance, but that this capacity in primary as well as more highly specialized levels of care is still very limited.
1) Primary care wait time tracking, analysis and improvements should be patient-centred, taking into account the whole wait time continuum that patients experience, starting from the time they first seek medical care.
2) More research and evaluation is needed to analyze primary care wait times so that the inequities and inconsistencies in access to care can be addressed for patients from region to region across Canada.
3) More study on collaborative care is necessary. The PCWTP recognizes that collaboration has the potential to enhance access to primary care. But before we can state with certainty that access to primary care is improved through particular models of care delivery, we need to continue to collect data and analyze results. It makes little sense to invest tremendous resources into any model if patient access to primary care is not improved.
4) Primary care wait time measurement should be a priority for Canadian governments, health authorities and other stakeholders, (e.g. Canadian Institute for Healthcare Information). Reliable data that represents the patient's total wait time experience will need to be collected to support the development of primary care wait time targets in the future. This data must be validated and tracked for the purpose of continuous evaluation.
5) Before reasonable wait time targets can be established and effectively used in primary care, information infrastructures, (e.g. electronic medical records and communication tools) , must be adequately supported and in place. Enhancements in information technology and learning in family practice will be necessary to facilitate the adoption and widespread use of electronic medical records. No measuring or tracking of primary care wait times can be effectively accomplished without financial support from government for electronic communication systems in and between medical practices.
6) There are a number of jurisdictions pursuing important and different ways to improve timely access to care for patients, (e.g. Manitoba's catalogue system and registry tool, Alberta's formal service agreements between referring and consulting physicians). These worthwhile endeavours should be monitored at a national level for opportunities to implement more universal improvements to wait times in our Canadian health care system.
Recommendations for Patients without a Family Physician
The CFPC and CMA have recommended and supported several strategies to increase the supply of family physicians through education and training (e.g. promotion of family medicine to medical students and residents, better support for preceptors and teachers), to address changing patterns of family practice (e.g. supports for inter-professional collaboration), and to develop models of care that would attract and retain family physicians (e.g. blended remuneration methods). While these recommendations will not be repeated here, they should be given full consideration in seeking to achieve an adequate family physician workforce that can support timely access to care for all Canadians.
1) The PCWTP believes that every Canadian should have a family doctor and supports the CFPC position that all stakeholders, (e.g. governments, medical schools and professional organizations), should work together to achieve a target of 95% of the population in every Canadian community with a family doctor by 2012.
2) Patient registries should be developed and maintained to track patients who do not have a family doctor and are actively looking for one.
3) Other strategies should be more fully developed and supported to find family doctors for patients without a family doctor , (e.g. physician incentives to accept new patients and the use of tools for workload management and patient flow in family practice).
4) Efforts currently underway to integrate appropriately trained and certified international medical graduates as family physicians into our health care system are welcome, should be supported and enhanced.
Recommendations for Patients who have a Family Physician
1) Family physicians who see a need to improve timely access to care for their patients could consider Clinical Practice Redesign tools such as Advanced Access . System support should be in place for family physicians who want to adopt these tools. The training and ongoing learning of new and practicing family physicians should include education in practice flow and design. To further assist physicians in the use of these tools, websites should be established with lists of those who have been successful at improving patient flow through their practices and who are willing to assist others attempting to do the same.
2) Practice management education and training should be enhanced in residency in order to teach new family physicians about effective office processes and practice flow efficiencies that improve timely access to care for patients, (e.g. electronic tracking tools).
3) Financial incentives should be available to support the valuable roles of office assistants as well as other health professionals in family practice, (e.g. family practice nurses), for better patient flow and more efficient use of the physician's time. In addition, family physician remuneration should compensate for patient encounters beyond just face-to-face in order to support increasingly important opportunities for electronic encounters with patients and members of the care team.
Recommendations for Referral from Primary to Specialty Care
1) All recommendations to address timely access to more highly specialized care must include the wait time from the first visit with the family physician to referral and specialty consultation.
2) Based on four years' experience with benchmarks for the five procedural areas established in 2004, we do not believe it is possible to develop a broad array of condition-specific, evidence-based benchmarks for access to consultations in the near future. However, where they are or do become available and are supported by sufficient infrastructure, wait time targets should be used as guides to drive improvements in timely access to care. Nonetheless, family physicians must continue to be free to use their clinical judgment in the patient's best interests.
3) Good intra-professional relationships between family physicians and other specialists should be promoted and supported in the health care system to improve communications and the continuity of care for patients. Strategies to support good relationships should consider recommendations that have been developed by the Canadian Medical Protective Association as well as the Collaborative Action Committee on Intra-professionalism that is supported by the CFPC and Royal College of Physicians and Surgeons of Canada with CMA participation.
4) Tools that will improve the timeliness of the referral-consultation process between physicians should also be enhanced; however, any development of referral-consultation process tools must be undertaken collaboratively with family physicians, (e.g. referral-consultation frameworks that identify and support the availability of appropriate and timely information to and from referring and consulting physicians, electronic communication of patient information between physicians, and better system supports for electronic communication between physicians and patients).
5) Family physicians should have access to routine and advanced diagnostic tests for their patients in all clinical settings, equal to that of other specialists. There should be no difference in the criteria for access to advanced diagnostic testing from region to region. All physicians should be expected to follow appropriate clinical guidelines in the use of diagnostic tests. These guidelines should be readily available and easily understood by physicians and other health care professionals with whom they work.
6) Guidelines or targets for timely access from primary to specialty care must account for differences in geographic settings and proximity to care that are characteristic of rural and remote locations in contrast to urban and suburban locations.
While the Canadian Medical Association (CMA) and The College of Family Physicians of Canada (CFPC) are proud to represent doctors across Canada, at the centre of everything we do stands the patient. We know that many Canadians are concerned about timely access to see their own family doctor while others continue a sometimes fruitless search for a family doctor of their own.
In this paper we have presented many problems but also a number of solutions to addressing wait times in primary care. We've acknowledged that there are obstacles, but we do not think these obstacles are insurmountable. Canadians exercised considerable political courage, often in the face of adversity, to pioneer a health care system based on the principles of fairness, equality and social justice. Through political will, we are certain we can make the changes necessary to ensure timely access to primary care.
The PCWTP hopes that governments, health care providers and the public will read this report and consider the recommendations. We know that these recommendations do not represent an exhaustive list and indeed we may have inadvertently omitted something you think is critical. We encourage you to let us know what you think and how we can work together to improve access to primary care.
This is not a task merely for the CFPC or the CMA; all of us must work together to offer better access to health care to our patients.
1Statistics Canada. Canadian community health survey: 2007 questionnaire. [Online][Accessed 2008 Nov 20]. Available from:
2The College of Family Physicians of Canada. CFPC Decima survey results. Toronto: Decima Research; November 2008. 3Statistics Canada. Frequency of whether taken care of by same medical doctor or nurse each visit by source of regular care. Canadian survey of experiences with primary care, 2007. Custom Tabulation.
4Glazier RH, Moineddin R, Agha MM, Zagorski B, Hall R, Manuel DG, et al. The impact of not having a primary care physician among people with chronic conditions. ICES investigative report. Toronto: Institute for Clinical Evaluative Sciences; 2008 Jul. 5Canadian Community Health Survey, 2007. Statistics Canada The Daily. [Online] [Accessed 2008 Nov 18]. Available from:
6American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home: March 2007. [Online] [Accessed 2008 Nov 19]. Available from: http://www.medicalhomeinfo.org/Joint%20Statement.pdf
7Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Aff 2007 Oct 31; 26(6):w717-34.
8Milliken O, Devlin RA, Barham V, Hogg W, Dahrouge S, Russell G. Comparative efficiency assessment of primary care models using data envelopment analysis. Ottawa: University of Ottawa; 2008 Mar.
9Lamarche PA, Beaulieu M-D, Pineault R, Contandriopoulos A-P, Denis J-L, Haggerty J. Choices for change: The path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation; 2003 Nov. 10Hutchison B, Østbye T, Barnsley J, Stewart M, Mathews M, Campbell MK, et al. Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: the Ontario walk-in clinic study. Can Med Assoc J 2003 Apr 15:168(8): 977-83.
11Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' accord on health renewal. [Online] [Accessed Nov 24]. Available from: http://www.scics.gc.ca/pdf/800039004_e.pdf
12Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. [Online] [Accesssed Nov 24]. Available from: http://www.scics.gc.ca/cinfo04/800042005_e.pdf
13Ontario Ministry of Health. First ever common benchmarks will allow Canadians to measure progress in reducing wait times. [Online][Accessed 2008 Nov 25]. Available from:
14Ipsos-Reid. Physicians today: Respect, reputation and role. Ottawa: Canadian Medical Association; 2007 Nov. 15The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. National Physician Survey. [Online] [Accessed 2008 Nov 14]. Available from:
Health Council of Canada. Canadian survey of experiences with primary health care in 2007. [Online] [Accessed 2008 Nov 25]. Available from:
Esmail N, Hazel M, Walker M. Waiting your turn: Hospital waiting lists in Canada, 2008 report, 18 edition. Fraser Institute. [Online][Accessed 2008 Nov 18]. Available from:
18Canadian Medical Protective Association. Wait times: a medical liability perspective. [Online] [Accessed 2008 Nov 24] Available from: http://www.cmpa-acpm.ca/cmpapd04a/pub_index.cfm?LANG=E&URL=cmpa%5Fdocs%2Fenglish%2Fcontent%2Fissues%2Fcommon%2Fcom %5Fwait%5Ftimes%5F2007%2De%2Ehtml
19Borsellino, M. 10 questions with...RCPSC president Dr. William Fitzgerald. The Medical Post. 2009 Jan 13. [Online][Accessed 2009 Feb 11]. Available from:
20Ross M. Limited health-care resources: the difficult balancing act. Information sheet IS0770E. Ottawa: Canadian Medical Protective Association; 2007.
21Ontario Medical Association, Ministry of Health and Long Term Care. Memorandum of agreement between: The OMA and the MOHLTC. 2008 Sep.
22Manitoba Health. Advanced access initiative. [Online][Accessed 2009 Jan 16]. Available from:
23Murray N, Berwick D. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035-40.
24Bartok B. Experts offer 'CPR' for your practice: Saskatchewan's Advanced Access school revives struggling practices. Nat R Med 2008 Apr. [Online] [Accessed 2008 Nov 25];5(4):[3 screens]. Available from:
25Department of Health. Patients get booking 'guarantee' on NHS GP appointments. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4118856
26Department of Health. GMS statement of financial entitlements. [Online][Accessed 2008 Nov 26]. Available from:
27The Information Centre. GP patient survey. [Online][Accessed 2008 Nov 26]. Available from: http://
28Department of Health. FOI releases: GP patient survey. [Online][Accessed 2008 Nov 26]. Available from:
29Berta W, Barnsley J, Brown A, Murray M. In the eyes of the beholder: Population perspectives on performance priorities for primary care in Canada. Healthc Policy 2008;4(2):86-100.
30British Medical Journal. Patients first. 1991 Nov 9;303:1153.
31Department of Health. The patient's charter & you. London: DOH; 1996 Nov.
32Department of Health. The NHS cancer plan and the new NHS. [Online][Accessed 2008 Nov 26]. Available from:
33Department of Health. About the programme - 18 weeks patient pathway. [Online][Accessed 2008 Nov 25]. Available from:
34Naylor CD, Baigrie RS, Goldman BS, Basinski A. Assessment of priority for coronary bypass revascularization procedures. Lancet 1990 May 5; 335:1070-73.
35Noseworthy TW, McGurran JJ, Hadorn DC, WCWL Steering Committee. Waiting for scheduled services in Canada: development of priority-setting scoring systems. J Eval Clin Pract 2002 Mar 22;9(1): 23-31.
36De Coster C, McMillan S, Brant R, McGurran J, Noseworthy T, WCWL Primary Care Panel. The western Canada wait list project: development of a priority referral score for hip and knee arthroplasty. J Eval Clin Pract 2005 Sep 26;13(2007):192-7. 37Saskatchewan Surgical Care Network. Patient assessment questionnaires, guides & urgency profiles for surgical procedures. [Online][Accessed 2008 Nov 25]. Available from: http://www.sasksurgery.ca/ayn-tools-scoringguides.htm
38Wait Time Alliance. Time for progress: new benchmarks for achieving meaningful reductions in wait times. Ottawa: Canadian Medical Association; 2007.
39The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD Lounge. 2008 Sep: 3.
40Canadian Medical Association. Health Policy & Negotiations Conference. Proceedings of the HP&N Conference. 2008 Oct 18-19; Ottawa.
41College of Physicians and Surgeons of Manitoba Newsletter. September 2005. [Online][Accessed 2008 Nov 24]. Available from: http://www.cpsm-secure.com/newsletter/05-09.php
42DeMone, B. Improving Family Physician and Specialist Communication & Coordination: Bridging General and Specialist Care (BGSC) & the Catalogue of Specialized Services (CSS). Presented at Taming of the Queue VI; 2009 Mar 26; Ottawa. [Online][Accessed 2009 Oct 28]. Available from: http://www.cfpc.ca/BGSCTQVI
43The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD lounge. 2008 Sep: 6-7.
44Borsellino, M. Manitoba developing wait time measurement registry. The Medical Post. 2008 Dec 22. [Online][Accessed 2009 Jan 19]. Available from: http://www.medicalpost.com/news/article.jsp?content=20081222_111206_13308&s=1
45Canadian Medical Association. Physician resource questionnaire. 1990.
46Primary care funding models in Ontario: new comprehensive care model available October 1, 2005. Ontario Medical Review 2005 Jul/Aug: 17-19.
47Ministry of Health Services. Full service practice incentive program. [Online][Accessed 2008 Nov 27]. Available from:
48Minister of Health, Medical Society of Nova Scotia. Physician services master agreement. 2008 Oct 29.
49Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: Primary care doctors' office systems, experiences, and views in seven countries. Health Aff 2006 Nov 2; 25(2006): w555-71.
50King N. Doctor, administrator, advocate recognized for work in health care. The Cape Breton Post. 2008 May 13. [Online][Accessed 2008 Nov 25]. Available from: http://www.capebretonpost.com/index.cfm?sid=134095&sc=145