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
across Canada.
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
practice structures.2
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
featured.
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
of Canadians.
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
THEME PILLAR
Foundations
1. Administration and Funding
2. Appropriate Infrastructure
3. Connected Care
Functions
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
Ongoing
Development
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.
Alberta
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.
British Columbia
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.
Manitoba
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
Health Teams.
New Brunswick
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.
Northwest Territories
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.
Nova Scotia
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.
Ontario
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.
Quebec
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
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
FOUNDATIONS
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).
ADMINISTRATION
& FUNDING
PAGE 7
APPROPRIATE
INFRASTRUCTURE
PAGE 9
CONNECTED CARE
PAGE 12
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
operations.
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
each PMH.
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
Professional Development).
External supports
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
the PMH.
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
information).
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
stakeholder groups.
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
health issue.43
10 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
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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
Social Accountability.
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—
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Practice integration with other care settings and services, a process enabled by integrating health
information technology.
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
service settings.
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
are required:51
Data standardization
Interoperable EMR and other health information
systems
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
PMH
Privacy for patient information
It is important to keep in mind that any patient information, generated during the provision of care,
belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act
(PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information.
Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of
EMRs50 for more information.
Canadian Foundation for Healthcare Improvement
The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative
Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with
specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait
times for accessing specialty care by enabling family physicians to more efficiently manage their patients in
primary care settings.
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14 A NEW VISION FOR CANADA Family Practice—
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FUNCTIONS
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.
ACCESSIBLE CARE
PAGE 15
COMMUNITY ADAPTIVENESS &
SOCIAL ACCOUNTABILITY
PAGE 17
COMPREHENSIVE TEAM-BASED
CARE WITH FAMILY PHYSICIAN
LEADERSHIP
PAGE 20
CONTINUITY OF CARE
PAGE 23
PATIENT & FAMILY PARTNERED CARE
PAGE 25
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
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Accessible primary care is fundamental to a highperforming
health care system and is considered by
patients52 and other health care organizations as one
of the most important characteristics of primary health
care. For care to be accessible, all patients should have
access to a family physician who acts as their most
responsible provider and is supported by a team of
qualified health professionals. Patients must be able
to access medical care and treatment when needed.
While most Canadians currently have a regular family
doctor,4 it is important that the goal be for everyone in
Canada to have access to their own family physicians.
Accessible care is about more than just quick access to
appointments. It does include timely access principles,
but also advanced access, virtual access, and teambased
approaches to care that ensure patients can be
seen by the most appropriate provider when they need
to be seen.
Because visits occur for different reasons it is not useful
to define appropriate wait times for each type of visit
unlike in other areas of health care, such as surgery.
Therefore, the focus in family practice should be on
enhancing access to ensure patients can access care
when they feel it is necessary. This is not to say that
family physicians in a PMH must be on call 24/7/365,
but that methods for patients to access care through
the design of practice operations and scheduling
should be given more attention. On the other hand,
as patients are offered more choice (e.g., by phone or
e-communication), they should also expect practices
to establish realistic parameters for what is reasonable.
Practices should communicate clearly about what kind of
provider availability and response time is reasonable to
expect depending on access method and availability of
resources. Obtaining this understanding from a practice’s
patients and striving to meet these expectations is a
By adopting advanced and timely access, virtual access, and team-based approaches, accessible
care ensures that patients can be seen quickly.
4.1 A PMH ensures patients have access to medical advice, and information on available care options 24
hours a day, 7 days a week, 365 days a year.
4.2 Every patient is registered with a PMH.
4.3 PMH practices offer scheduling options that ensure timely access to appropriate care.
4.4 When the patient’s personal family physician is unavailable, appointments are made with another
physician, nurse, or other qualified health professional member of the PMH team.
4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking
system.
4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and
safe, high-quality care.
After-hours 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
Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment
and also consults another provider in the interim), improves health outcomes, leads to better patient and provider
satisfaction, and reduces emergency visits.56–58
16 A NEW VISION FOR CANADA Family Practice—
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good way to maintain the patient-centred focus of the
practice as described in Pillar 1: Administration and
Funding. Significant shifts in providing alternative access
must be supported by funding bodies.
Same-day scheduling has been introduced in many
PMH practices to better accommodate patient needs.
Frequently referred to as doing “today’s work today,”
advanced access offers the vast majority of patients the
opportunity to book their appointments on the day they
call regardless of the reason for the visit.60 Read more
about same day scheduling in the Best Advice guide:
Timely Access to Appointments in Family Practice.61
Whenever possible, patients should have clear reasons
for the appointment at the time of booking. This ensures
that adequate time is planned for each patient visit. If
the need to address multiple problems arises, the
problems can be triaged on the spot by one of the team
and arrangements made to have these concerns dealt
with in a timely manner either during the same visit or at
another time.
It is not always possible for patients to book appointments
with their most responsible family physician. To ensure
continuity, appointments can be made with other
physicians or health care professionals in the team. The
decision about who provides care in these cases is based
on the patient’s needs, the availability of team members,
and the scope of practice for each team member. In these
cases, any relevant information from the appointment
is communicated to the most responsible provider and
taken into account in the long-term care of the patient.
PMH practices can further meet patients’ needs through
extended office hours, in which the responsibilities for
coverage and care are shared by family physicians in one
or more practices, as well as by increased involvement of
other team members. PMH practices also provide their
patients with email, after-hours telephone, and virtual
services to guide them to the right place at the right
time for the care they need. Appropriately directing
patients to the next available appointment, or to a
hospital or another emergency service, is critical to the
effective management and sustainability of our health
care system.62,63 A PMH can help ensure that patients
are aware of where they can go to access care and
health information 24 hours a day, 365 days a year by
providing this information to patients in person or via
other systems (website, voice mail messages, etc.).
In alignment with Pillar 9: Measurement, Continuous
Quality Improvement, and Research, PMH practices offer
opportunities for patients to provide feedback on the
accessibility of the practice. Specifically, patients should
have the opportunity to evaluate and provide input for the
appointment booking system. Mechanisms and supports
need to be in place to ensure that practices and governing
bodies can review and respond to feedback appropriately
and communicate this back to patients.
Determining the optimal panel size for each PMH practice
is critical to ensuring accessible and safe, high-quality
care.64 Establishing and incorporating recommendations
from the PMH vision may enable practices to consider
increasing their panel size. Actual panel size will vary
depending on the number of physicians and other team
members in the practice, the practice’s obligations and
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Social accountability refers to the family physicians’
obligation to meet the needs of Canada’s
communities.66 For health care to be socially
accountable, it must be accessible by everyone and
responsive to the needs of patients, communities, and
the broader population.4 This obligation is embedded
in the Family Medicine Professional Profile and the
Four Principles of Family Medicine, highlighting that
family physicians are community-adaptive, responding
to the needs of their patients and communities.
These principles of family medicine align well with
the principles of social accountability. Family practice
is relationship-based care that embraces all issues
of need and endures over time and place of care. A
generalist keeps the whole in mind while attending
to the individual parts, the system in mind when
fixing individual problems, and the end in mind
when commencing the journey. Tools exist to help
family physicians and other health care providers
enhance their skills and training regarding social
accountability and cultural safety through many
professional organizations and cross-Canada
resource hubs like the National Collaborating
Centre of Determinants of Health67 and the National
Collaborating Centre on Aboriginal Health,68 as
examples.
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.
5.4
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
doing so.
5.5
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
information.65
issues that affect patients’ SDoH. Advocating for patients
and the health care system overall is a natural part of a
PMH structure. Advocacy can occur at three levels:69
Micro: In the immediate clinical environment, daily
work with individual patients and predicated on
the principles of caring and compassion
Meso: In the local community, including the
patient’s cultural community, the local community
of medical providers, and the larger civic
community, in which health professionals are
citizens as well as practitioners
Macro: In the humanitarian realm, where physicians
are concerned with the welfare of their entire
patient population and seek to improve human
welfare through healthy public policy (such as
reducing income inequality, supporting equitable
and progressive taxation, and expanding the
social safety net)
The principles of advocacy in family practice are found
in the CanMEDS–Family Medicine 201769 competency
framework, under the Health Advocate role. The
Best Advice guide: Social Determinants of Health70
describes how family physicians in the PMH can make
advocacy a practical part of their practice.
Poverty is a significant risk factor for chronic disease,
mental illness, and other health conditions. Low income
and other SDoH also present significant barriers to
accessing care.71 To meet the needs of these patients,
practices may need to extend hours, be more flexible
and responsive, and spend additional time helping
patients navigate and access necessary care. PMH
practices consider other specific community needs when
determining appropriate panel size. Demographics and
health status of the patient population can influence the
length and frequency of appointments needed, thereby
impacting a physician’s caseload.65 For example, a PMH
in a community with high rates of chronic conditions
may need to reduce the panel size to provide timely and
high-quality care, given that patients require more care
time and resources. Similarly, a patient’s social situation
may impact the time a family physician spends with
them. Family physicians and team members may need to
use a translator at clinical appointments, and may need
to provide written resources in alternative languages,
all factors affecting the time required to provide care.
Enabling PMH practices to adjust panel size based on
community needs requires governments to establish
blended payment mechanisms. These remuneration
systems ensure family physicians are adequately
compensated, and are not financially disincentivized from
spending the necessary time with patients (see Pillar 1:
Administration and Funding, for more information).
Social accountability and cultural competency
Part of the response to being more socially accountable with care offered to the community resides within each
and every health professional. While courses on cultural competency are now a standard part of medical education,
physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases
that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is
a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the
satisfaction of being an effective healer—of ourselves, our patients and our societies.
Importance of social accountability
Social accountability is a key value for health care organizations and professionals. For example, the Royal College
of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of
Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability
within their organizations and the work they do.
18 A NEW VISION FOR CANADA Family Practice—
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Family physicians and their PMH teams are situated
at the nexus of individual and population health, and
can engage with their patients in addressing health
promotion and disease prevention in creative ways. From
accompanying individual patients through teachable
moments (e.g., the smoker with pneumonia ready to quit)
to influencing civic policy to address homelessness, the
stories entrusted to family physicians in daily practice
are powerful tools for healthy change. These teams
are also key providers in many important public health
areas, including illness and injury prevention; health
promotion; screening and managing chronic diseases;
immunizations; and health surveillance. PMH practices
prioritize delivering evidence-based care for illness and
injury prevention and health promotion, reinforcing
them at each patient visit and other counselling
opportunities. PMHs and local or regional public health
units should cultivate and maintain strong links with one
another. Health care professionals who are part of PMH
teams may take on advisory, educational, supportive, or
active roles in public health initiatives, in many different
occupational, educational, or recreational settings
throughout the community. An effective public health
system should be inextricably linked to communitybased
family physicians and PMHs, recognizing and
supporting them as essential to the achievement of the
broader population and public health goals.
While PMHs focus primarily on the care of individuals
and their families, it is important for team members to
understand and address the health challenges facing
their practice populations and the larger community.
These broader challenges represent upstream factors
(SDoH) that have greater impact on the health of patients
than do the efforts of individual physicians. However,
the relationships embedded in individual and collective
practices can be central to engaging patients and
citizens in building more just and healthier communities
and societies. For example, with the help of HIT, details
about the needs of populations can be more easily
accessed through extraction from practice EMRs, or
participation in programs such as the Canadian Primary
Care Sentinel Surveillance Network (CPCSSN).73 The
CPCSSN networks collect health information from
EMRs of participating primary care providers, extract
anonymous data, and share information on chronic
conditions with governments, health care providers,
and researchers to help inform meaningful systems
and practice change. Programs like the CPCSSN allow
practices to better understand the needs of their
communities and implement specific health promotion
and prevention programs that can contribute to the
population’s overall well-being. Initiatives like this also
ensure the avoidance of data duplication, and recognise
that practices do not need (or have the resources) to
collect data on their own. However, these data are just
a part of caring—the heart of generalism is keeping the
whole in mind while attending to its parts, whether it is
at the level of the whole patient, the whole family, or the
whole society.
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
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Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership
Primary care practice teams
Many allied health professional organizations have prioritized the importance of working together in a team to
provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the
CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of
Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes
implementation strategies for creating a primary practice team, and general descriptions of roles found in a
collaborative team.
20 A NEW VISION FOR CANADA Family Practice—
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A broad range of services is offered by an interprofessional team. The patient does not always see
their family physician but interactions with all team members are communicated efficiently within a
PMH. The team might not be co-located but the patient is always seen by a professional with relevant
skills who can connect with a physician (ideally the patient’s own personal physician) as necessary.
6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel
of registered patients.
6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or
network, collaborating with the patient’s personal family physician to provide timely access to a broad range
of primary care and consulting services.
6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged
and supported as part of each PMH.
6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team
members may be co-located or may function as part of virtual networks.
6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the
roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers,
physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed.
6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing
ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal
medical home team.
6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles,
professional scopes of practice, and personally acquired competencies. Their roles providing both episodic
and ongoing care support and complement—but do not replace—those of the family physician.
Team-based care is a core function of the PMH. Building
a team with a diverse mix of professional backgrounds
creates an opportunity to redefine what is considered
optimal, based on the needs of the practice and the
community it serves. A high-performing team is essential
to delivering more comprehensive, coordinated, and
effective care centred on the patient’s needs. While
different circumstances call for aspects of patient care
to be provided by different health professionals, it is
important to ensure that family physician expertise is
available to all team members through consultation.
To practice effectively in an interprofessional health care
team, there must be a clear understanding of each member’s
unique contributions, including educational background,
scopes of practice and knowledge, and areas of excellence
and limitations.76 Practices that draw on the expertise of a
variety of team members are more likely to provide patients
with the care they need and respond to community needs.77
Relationships across all dynamics within a practice,
whether between a patient and family physician or
between a patient and other members of the team,
should be encouraged and supported in the PMH.
Establishing these relationships develops trust and
confidence, and works toward the ultimate goal of
achieving better health outcomes. While it should be
left to each practice to determine who does what (within
the boundaries of professional scopes of practice), the
most responsible provider for the medical care for each
patient in the practice should be the patient’s personal
family physician.
Family physicians with enhanced skills and family
physicians with focused practices play an important role in
collaborating with the patient’s personal family physician
and team to provide timely access to a range of primary
care and consulting services. They supplement their
core skills and experience with additional expertise in a
particular field, while remaining committed to their core
generalist principles.78 These doctors can draw extensively
on their generalist training and approach to disease
management and patient-centred care, enabling them to
work collaboratively at different levels of care, including
with other specialists, to meet patient needs.79 These
clinicians also serve as a resource for other physicians in
their local health system by enhancing care delivery and
learning and teaching opportunities. The Best Advice
guide: Communities of Practice in the Patient’s Medical
Home80 provides more information about intraprofessional
collaboration between family physicians.
Shared care strategies provide patients with timely access
to consultations with other specialists or family physicians
with enhanced skills at scheduled times in the family
practice office setting. The consultant might assess several
patients per visit, at which time a plan for ongoing care
can be developed and agreed to by the family physician,
consultant, other team members, and the patient.
There is no one-size-fits-all model when determining
what mix of health care professionals is right. Team
composition depends on the professional competencies,
skills, and experiences needed to address the health
needs of the patient population.81 These needs vary,
depending on the communities’ defining characteristics;
Additional members of practice teams
Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice
can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices
can also host other health care professionals, such as those employed with a regional health authority, to provide
care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other
health care professionals often carry the overhead costs associated with these practitioners working on site,
and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1:
Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly
funded and have access to the right infrastructure (physical and governance) to support the initiatives described
in this vision.
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22 A NEW VISION FOR CANADA Family Practice—
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for example, geography, culture, language, demographics,
disease prevalence. Family physicians are encouraged
to identify the gaps in health care provision in the local
practice environment and work with other health care
providers to meet those needs as much as possible. Data
from EMRs—as well as input from patients, community
members, and stakeholders—should inform team
planning. Factors to consider include:
Patient population
Identified community health care needs
Hours available for patient access
Hours available for each physician to work
Roles and number of non-physician providers
Funds available81
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
residence.
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
their environment.
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
process.
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).
Patient self-management
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
ONGOING DEVELOPMENT
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
Development.
MEASUREMENT,
CONTINUOUS
QUALITY
IMPROVEMENT,
AND RESEARCH
PAGE 28
TRAINING,
EDUCATION, AND
CONTINUING
PROFESSIONAL
DEVELOPMENT
PAGE 30
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
full population.
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,
and programs.
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
chronic diseases.
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
dedicated time.
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
competencies.
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
described:
Socially responsive to the needs of patients and
communities
Informed by scientific evidence and practicebased
data
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
patient care.
† 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
CONCLUSION
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
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