CHILD AND YOUTH HEALTH IN CANADA
THEIR CHARTER — OUR CHALLENGE
“There can be no keener revelation of a society’s soul than the way it treats its children.”
“One generation plants the trees; another gets the shade.”
Children and youth have always been a priority for the doctors of Canada — the Child and
Youth Health Initiative of the Canadian Medical Association, the Canadian Paediatric
Society and the College of Family Physicians of Canada is evidence of that. We three
organizations joined together in November 2006 to launch the Child and Youth Health
In September 2004, Canada’s first ministers committed to “improving the health status of Canadians through a collaborative process.” This led to an agreement on health goals for Canada. The first of them is “Our children reach their full potential, growing up happy, healthy, confident and secure.” At the international level, the United Nations Convention on the Rights of the Child sets out the wider rights of all children and young people, including the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. We now owe it to our children and youth to develop tangible health goals and targets.
From the outset of the partnership, we were acutely aware that only a broad societal
coalition could achieve the overarching goal of excellence in child and youth health in
Canada. Making the health of children and youth a national priority requires a coalition of
child and youth health champions, including governments, parents, health providers,
businesses, schools, teachers and communities.
To start that process, we created Canada’s Child and Youth Health Charter. An action
framework was then developed called Canada’s Child and Youth Health Challenge because a charter alone will not deliver on the vision of the children and youth of Canada being among the healthiest in the world. Together, we believe they will help to build a coalition of child and youth health champions because they give the people who can make a difference in children and youth health a rallying point.
The credibility and success of the Charter and the Challenge require broad, inclusive
consultation and a commitment to child and youth health from society at large. The Child
and Youth Health Summit, held April 25-26, 2007, was about consultation and commitment
to making a difference to the health and well-being of children and youth.
This document contains Canada’s Child and Youth Health Charter, which was one of the
focuses of the summit. Canada’s Child and Youth Health Challenge and Canada’s Child and Youth Health Declaration, are the other components of our commitment and promise to take action for the children of Canada. These documents can be found at www.ourchildren.ca.
Canada’s Child and Youth Health Charter
In 2005, Canada’s federal, provincial and territorial governments created pan-Canadian
health goals. The first of them is “Canada is a country where: Our children reach their full
potential, growing up happy, healthy, confident and secure.”
To reach their potential, children and youth need to grow up in a place where they can thrive
— spiritually, emotionally, mentally, physically and intellectually — and get high-quality
health care when they need it. That place must have three fundamental elements: a safe and
secure environment; good health and development; and a full range of health resources
available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children
and youth through culturally relevant resources.
Canada must become:
1. A place with a safe and secure environment:
a) Clean water, air and soil;
b) Protection from injury, exploitation and discrimination; and
c) Healthy family, homes and communities.
2. A place where children and youth can have good health and development:
a) Prenatal and maternal care for the best possible health at birth;
b) Nutrition for proper growth, development and long-term health;
c) Early learning opportunities and high-quality care, at home and in the community;
d) Opportunities and encouragement for physical activity;
e) High-quality primary and secondary education;
f) Affordable and available post-secondary education; and
g) A commitment to social well-being and mental health.
3. A place where a full range of health resources is available:
a) Basic health care including immunization, drugs and dental health;
b) Mental health care and early help programs for children and youth;
c) Timely access to specialty diagnostic and health services;
d) Measurement and tracking the health of children and youth;
e) Research that focuses on the needs of children and youth; and
f) Uninterrupted care as youth move to adult health services and between acute,
chronic and community care, as well as between jurisdictions.
1. The principles of this charter apply to all children and youth in Canada regardless of
race, ethnicity, creed, language, gender, physical ability, mental ability, cultural history, or
2. Principles enshrined in all the goal statements include:
a. Universality: The charter applies equally to all children and youth residing in
Canada and covers all children and youth from 0-18 years of age.
b. Without financial burden: All children and youth in Canada should have access
to required health care, health services and drugs regardless of ability to pay.
c. Barrier-free access: All children and youth, regardless of ability or circumstance
should have appropriate access to optimal health care and health services.
d. Measurement and monitoring: Appropriate resources will be available for
adequate ongoing collection of data on issues that affect child and youth health
e. Safe and secure communities: Communities in Canada must create an
environment for children and youth to grow that is safe and secure.
3. The purpose of this charter is to facilitate development of specific goals, objectives,
actions and advocacy that will measurably improve child and youth health throughout
4. Success will be identified as simple, measurable, achievable, and timely goals and
objectives for each of the 16 statements in this charter.
5. The initial draft of this charter has been developed by Canada’s physicians focusing on
what they can best do to improve child and youth health; however, the support and
participation of all individuals and groups interested in child and youth health is
encouraged and desired.
6. The primary audience for actions and advocacy arising from this charter will be
governments, agencies or individuals who, by virtue of legislation, regulation or policy
have the ability to effect change for children and youth.
7. This charter is not a legal document; it represents a commitment by champions of child
and youth health in Canada to the health and well-being of all children and youth in
The following organizations have endorsed the Child and Youth Health Charter, as of
October 9, 2007.
Association of Canadian Academic Healthcare Organizations
Boys and Girls Clubs of Canada
Breakfast for Learning
Canadian Association of Paediatric Health Centres
Canadian Child and Youth Health Coalition
Canadian Healthcare Association
Canadian Institute of Child Health
Canadian Medical Association
Canadian Paediatric Society
Canadian Pharmacists Association
Canadian Psychological Association
Centre of Excellence for Early Childhood Development
Centre for Science in the Public Interest
College of Family Physicians of Canada
Landon Pearson Resource Centre for the Study of Childhood and Children's Rights
National Alliance for Children and Youth
National Anti-Poverty Organization
Newfoundland and Labrador Medical Association
Paediatric Chairs of Canada
Safe Kids Canada, The National Injury Prevention Program of The Hospital for Sick Children
Silken's ActiveKids Movement and Silken and Company Productions
The Royal College of Physicians and Surgeons of Canada
Homeless and vulnerably housed populations are heterogeneous
and continue to grow in numbers in urban and
rural settings as forces of urbanization collide with gentrification and austerity policies.2
Collectively, they face dangerous living conditions and marginalization within health care systems.3
However, providers can improve the health of people who
are homeless or vulnerably housed, most powerfully by following
evidence-based initial steps, and working with communities and
adopting anti-oppressive practices.1,4,5
Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6
Under such conditions, individuals and families face intersecting
social, mental and physical health risks that significantly increase
morbidity and mortality.7,8 For example, people who are homeless
and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports
that people who experience homelessness face life expectancies
as low as 42 years for men and 52 years for women.7
A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth,
Indigenous people (Box 1), immigrants, older adults and people
from rural communities.13,14 For example, family homelessness
(and therefore homelessness among dependent children and
youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of
the estimated 235 000 homeless people in Canada, 27.3% were
women, 18.7% were youth, 6% were recent immigrants or
migrants, and a growing number were veterans and seniors.10
Practice navigators, peer-support workers and primary care
providers are well placed to identify social causes of poor health
and provide orientation to patient medical homes.16,17 A patient’s
medical home is “a family practice defined by its patients as the
place they feel most comfortable presenting and discussing their
personal and family health and medical concerns.”18 Medical
care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated
with other services in the health care system and the community”
(https://patientsmedicalhome.ca). Primary care providers are
also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19
GUIDELINE VULNERABLE POPULATIONS CPD
Clinical guideline for homeless and vulnerably
housed people, and people with lived
Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH,
Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD,
Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD,
Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW,
Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD,
Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA,
Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD
n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199
Clinical assessment and care of homeless and vulnerably housed
populations should include tailoring approaches to a person’s
gender, age, Indigenous heritage, ethnicity and history of
trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed
populations, permanent supportive housing is strongly
recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric
support, are recommended as an initial step to support primary
care and to address existing mental health, substance use and
Harm-reduction interventions, such as supervised consumption
facilities, and access to pharmacologic agents for opioid use
disorder, such as opioid agonist treatment, are recommended
for people who use substances.
MARCH 9, 2020
ISSUE 10 E241
However, the social and health resources available to homeless
and vulnerably housed people may vary based on geographic
setting, municipal resources, housing coordination, and patients’
mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities
for care, patient mistrust of the health care system or limited
access to health services.3
Homeless and vulnerably housed people can benefit from
timely and effective health, addiction and social interventions.
Our guideline provides initial steps for practice, policy and future
research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values
such as trauma-informed and patient-centred care, and dignity
are needed to foster trust and develop sustainable therapeutic
relationships with homeless and vulnerably housed people.20,21
The purpose of this clinical practice guideline is to inform providers
and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The
guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers.
Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the
many etiologies of homelessness, such as childhood trauma, the
housing market, or the root causes of low social assistance rates
and economic inequality. Rather, this guideline aims to reframe
providers’ approach toward upstream interventions that can
prevent, treat and work toward ending the morbidity and mortality associated with homelessness.
A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led
team.22 This process recognizes the distinct rights of Indigenous
Peoples, including the right to develop and strengthen their own
economies, social and political institutions; the direct links
between historic and ongoing colonial policies and Indigenous
homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples.
The steering committee and guideline panel members developed
and approved recommendations to improve social and health
outcomes for homeless and vulnerably housed people. The order
of these recommendations highlights priority steps for homeless
health care. We list a summary of the recommendations in Table 1
and we present our list of good practice statements in Table 2.
These good practice statements are based on indirect evidence
and support the delivery of the recommendations.
The methods used to develop the recommendations are
described later in this document. A summary of how to use this
guideline is available in Box 2.
Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to
local housing coordinator or case manager (i.e., call 211 or
via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation).
Our systematic review (Tim Aubry, University of Ottawa, Ottawa,
Ont.: unpublished data, 2020) identified 14 trials on permanent
supportive housing (PSH).30–43 Several trials across Canada and the
United States showed that PSH initiatives house participants more
rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30
increase the number of people who maintain stable housing at
2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and
significantly increase the percentage of days spent stably
housed.41 No trials showed a significant improvement in mental
health symptoms compared with standard care.30,31,33,34,41,42
Two studies found that the mental health of PSH participants did
not improve as much as that of usual care participants (e.g., mean
difference –0.49, 95% CI –0.85 to –0.12).30,31
The At Home/Chez Soi trial showed small improvements in quality
of life for high-needs (adjusted standardized mean difference 0.15,
95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37,
95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41
Youth receiving PSH saw larger improvements in their quality of life
during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24),
which diminished over time (mean difference 7.29, 95% CI –1.61 to
16.18).44 No trials showed a significant improvement in substance use
compared with standard care.30,33,41–43 Most trials reported no effect of
PSH on acute care outcomes (e.g., number of emergency department
visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital
admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found
no effect of PSH on job tenure, hours of work per week or hourly wage
compared with standard care.46 Participants receiving PSH may have
increased odds of employment, but this depends on the severity of
participant needs.46 One trial found no effect on income outcomes.46
Box 1: Indigenous homelessness
Indigenous homelessness is a term used to describe First Nations,
Métis and Inuit individuals, families or communities who lack
stable, permanent and appropriate housing, or the immediate
prospects, means or ability to acquire such housing. However, this
term must be interpreted through an Indigenous lens to
understand the factors contributing to this condition. These
factors include individuals, families and communities isolated
from their relationships to land, water, place, family, kin, each
other, animals, cultures, languages and identities as well as the
legacy of colonialism and genocide.11 It is estimated that urban
Indigenous people are 8 times more likely to experience
homelessness than the general population.11,12
The certainty of the evidence was rated moderate, because
blinding of participants and personnel was not feasible in any of
the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which
could introduce high risks of detection and performance biases.
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation).
We identified 10 trials on income-assistance interventions, including
rental assistance,47–56 financial empowerment,47 social enterprise
interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that
income-assistance interventions have on housing stability (Gary
Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020).
Rental assistance increased the likelihood of being stably housed
(OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with
case management increased the number of days in stable housing
per 90-day period compared with case management alone (mean
Table 1: Summary of evidence-based recommendations
Recommendations and clinical considerations Grade rating*
Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call
211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system.
Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized
populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those
with disabilities, refugees and migrants.
Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or
living in a low-income household
Assist individuals with income insecurity to identify income-support resources and access income.
Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products
Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs
(including mental illness and/or substance use)
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with
substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to
intensive case management, assertive community treatment or critical time intervention where available.
Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar
with local access points and less intensive community mental health programs.
Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in
collaboration with a public health or community health centre for linkage to pharmacologic interventions.
Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers
to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT
access and options in your jurisdiction, in particular for buprenorphine.
Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services
(e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as
public health or community health centre or local community services centre.
Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be
made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/
Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited.
*See Box 2 for definitions.
†211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and
referrals to health, human and social service organizations.
ISSUE 10 E243
difference 8.58, p < 0.004).55 Compensated work therapy was found
to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No
income interventions showed an effect on mental health
The impact of these interventions on substance use outcomes
were mixed. Provision of housing vouchers did not affect substance
use over 3 years;55 however, compensated work therapy showed
immediate reductions in drug (reduction: –44.7%, standard error [SE]
12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p =
0.001), as well as the number of substance use–related physical
symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found
on overall quality-of-life, finances, health and social relations scores.
Provision of housing vouchers resulted in higher family-relations
score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated
with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to
improve employment rates only when there was high fidelity to the
model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54
Provision of housing vouchers had no effect on monthly income.55
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance
programs after completing the study had incentives to underreport
symptoms, which introduced high risk for measurement bias.
Identify history of severe mental illness, such as psychotic or
mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex
Ensure access to local community mental health programs,
psychiatric services for assessment and linkage to intensive
case management, assertive community treatment or critical
time intervention where available (low certainty, conditional
Our systematic review examined the effectiveness of standard
case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention
among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa,
Ottawa, Ont.: unpublished data, 2020). We included a total of
56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73
16 trials on intensive case management74–89 and 5 trials on critical
Box 2: How to use and understand this GRADE guideline
This guideline supplies providers with evidence for decisions
concerning interventions to improve health and social outcomes
for people who are homeless or vulnerably housed. This guideline
is not meant to replace clinical judgment. Statements about
clinical considerations, values and preferences are integral parts of
the recommendations meant to facilitate interpretation and
implementation of the guideline. Recommendations in this
guideline are categorized according to the Grading of
Recommendations Assessment, Development and Evaluation
(GRADE) system as strong or conditional recommendations.
Strong recommendations indicate that all or almost all fully
informed patients would choose the recommended course of
action, and indicate to clinicians that the recommendation is
appropriate for all or almost all individuals. Strong
recommendations represent candidates for quality-of-care criteria
or performance indicators.
Conditional recommendations indicate that most informed
patients would choose the suggested course of action, but an
appreciable minority would not. With conditional
recommendations, clinicians should recognize that different
choices will be appropriate for individual patients, and they should
help patients arrive at a decision consistent with their values and
preferences. Conditional recommendations should not be used as
a basis for standards of practice (other than to mandate shared
Good practice statements represent common-sense practice, are
supported by indirect evidence and are associated with assumed
large net benefit.
Clinical considerations provide practical suggestions to support
implementation of the GRADE recommendation.
GRADE certainty ratings
High: further research is very unlikely to change our confidence in
the estimate of effect.
Moderate: further research is likely to have an important impact on
the confidence in the estimate of effect and may change the estimate.
Low: further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change
Very low: any estimate of the effect is very uncertain.
Table 2: Good practice statements to support delivery of care
Good practice statement
1. Homeless and vulnerably housed populations
should receive trauma-informed and personcentred care.
2. Homeless and vulnerably housed populations
should be linked to comprehensive primary
care to facilitate the management of multiple
health and social needs.
3. Providers should collaborate with public health
and community organizations to ensure
programs are accessible and resources
appropriate to meet local patient needs.
Of 10 trials on standard case management, 10 evaluated
housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a
time-limited residential case management in which participants
in all groups accessed substantial levels of services.57 A program
tailored to women reduced the odds of depression at 3 months
(OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in
the women’s overall mental health status (mean difference 4.50,
95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female
participants receiving nurse-led standard case management
compared with those receiving standard care.60 Few studies
reported on substance use, quality of life, employment or
Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are
mixed. Two trials found that participants receiving the treatment
reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect
on episodes of homelessness or number of days homeless.66,73
Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department
(mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental
health outcomes, including psychiatric symptoms, substance
use, or income-related outcomes between the treatment and
Intensive case management reduced the number of days
homeless (pooled standardized mean difference –0.22, 95% CI
–0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in
psychological symptoms between the treatment and control
groups. However, 1 trial reported significantly greater reductions
in anxiety, depression and thought disturbances after 24 months
(mean difference change from baseline –0.32, p = 0.007), as well
as improved life satisfaction (mean difference 1.23, p = 0.001)
using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use
were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use
behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department
(mean difference 19%, p < 0.05) but did not have shorter hospital
stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on
income received from employment; however, income received
by participants through public assistance increased (e.g., mean
difference 89, 95% CI 8 to 170).78,85
Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the
odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the
final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard
care,95 but did not spend more days rehoused.90 Adults receiving
critical time intervention showed significant improvements in
psychological symptoms (mean difference –0.14, 95% CI –0.29 to
0.01).90 However, findings for children’s mental health were
mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86),
whereas changes for children aged 6–10 years and 11–16 years
were not significant.93 There were no significant effects of critical
time intervention on substance-use,90 quality-of-life90,92 or
income-related outcomes.96 Two trials reported mixed findings
on hospital admission outcomes; in 1 study, allocation to critical
time intervention was associated with reduced odds of hospital
admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of
nights in hospital (p < 0.05) in the final 18 weeks of the trial.97
However, another study reported a greater total number of
nights in hospital for the treatment group compared with usual
care (1171 v. 912).98
The certainty of the evidence was rated low because several
trials introduced high risk of detection and performance bias.
Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by
referral to an addiction specialist, potentially in collaboration
with public health or community health centre for linkage to
pharmacologic interventions (low certainty, conditional
We conducted a review of systematic reviews on pharmalogic
interventions for opioid use disorder.99 Twenty-four reviews,
which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general
populations.100–123 We expanded our inclusion criteria to general
populations, aware that most studies among “general populations” had a large representation of homeless populations in
their samples. We did not identify any substantial reason to
believe that the mechanisms of action of our interventions of
interest would differ between homeless populations who use
substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on
the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and
hydromorphone for treatment of opioid use disorder.
We found pooled all-cause mortality rates of 36.1 and 11.3 per
1000 person years for participants out of and in methadone
maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to
3.86), and mortality rates of 9.5 per 1000 person years for those
not receiving buprenorphine maintenance therapy compared
with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific
mortality rates were similarly affected, with pooled overdose
mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates
of 4.6 and 1.4 per 1000 person years out of and in buprenorphine
maintenance therapy.116 Compared with nonpharmacologic
approaches, methadone maintenance therapy had no significant
ISSUE 10 E245
effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With
respect to morbidity, pharmacologic interventions for opioid use
disorder reduced the risk of hepatitis C virus (HCV) acquisition
(risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103
Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with
reduced illicit opioid use (standardized mean difference –1.17,
95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment
expanded access to treatment for patients unlikely to enrol in
methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear;
however, use of methadone was found to show better benefits
than nonpharmacologic interventions for retention (risk ratio
4.44, 95% CI 3.26 to 6.04).110
The certainty of evidence ranged from very low to moderate,
primarily because of inconsistency, high risk of bias and evidence
from nonrandomized studies.
Identify problematic substance use, including alcohol or other
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised
consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community
health centre or les centres locaux de services communautaires (low certainty, conditional recommendation).
We conducted a review of systematic reviews on supervised
consumption facilities and managed alcohol programs.99 Two
systematic reviews, which included 90 unique observational
studies and 1 qualitative meta-synthesis reported on supervised
consumption facilities.124–126 For managed alcohol programs,
1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129
Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per
100 000 person years, p = 0.048), compared with 9% in the rest of
the city (Vancouver).124 There were 336 reported opioid overdose
reversals in 90 different individuals within the Vancouver facility
over a 4-year period (2004–2008).125 Similar protective effects
were reported in Australia and Germany. Observational studies
conducted in Vancouver and Sydney showed that regular use of
supervised consumption facilities was associated with decreased
syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe
reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space
injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter)
and fostered access to broader health support.125,126 Attendance
at supervised consumption facilities was associated with an
increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio
1.57, 95% CI 1.02 to 2.40).125
Evidence on supervised consumption facilities was rated very
low to low, as all available evidence originated from nonrandomized studies.
There was a lack of high-quality evidence for managed alcohol
programs. Few studies reported on deaths among clients of these
programs.128 The effects of managed alcohol programs on hepatic
function are mixed, with some studies reporting improvement in
hepatic laboratory markers over time, and others showing
increases in alcohol-related hepatic damage;129 however, this may
have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with
medical and social services.128 Clients experienced significantly
fewer social, health, safety and legal harms related to alcohol
consumption.129 Individuals participating in these programs had
fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129
Cost effectiveness and resource implications
Permanent supportive housing
We found 19 studies assessing the cost and net cost of housing
interventions.30,41,45,130–145 In some studies, permanent supportive
housing interventions were associated with increased cost to the
payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the
intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies,
however, employed a pre–post design.135,139,141,145 Moreover,
1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased
quality-adjusted life years, with an incremental cost-effectiveness
ratio of US$62 493 per quality-adjusted life year.136 Compared
with usual care, PSH was found to be more costly to society (net
cost Can$7868, 95% CI $4409 to $11 405).138
Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving
case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received
income assistance incurred additional costs of US$58 (95% CI $4
to $111) from the perspective of the payer, US$50 (95% CI –$17 to
$117) from the perspective of the health care system and US$45
(95% CI –$19 to $108) from the societal perspective. The benefit
gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146
Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150
Findings of these studies were mixed; the total cost incurred by
clients of standard case management was higher than that of
clients receiving usual or standard care61,88 and assertive
community treatment,67,147 but lower compared with a US clinical
case-management program that included housing vouchers and
intensive case management.55 Cost-effectiveness studies using a
societal perspective showed that standard case management
was not cost effective compared with assertive community
treatment for people with serious mental disorders or those with
a concurrent substance-use disorder, as it was more expensive.67
For intensive case management, the cost of supporting housing
with this program could be partially offset by reductions in the use
of emergency shelters and temporary residences.41 Intensive case
management is more likely to be cost effective when all costs and
benefits to society are considered.41 A pre–post study showed that
providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150
Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We
identified only 1 study on the cost effectiveness of critical time
intervention that reported comparable costs (US$52 574 v.
US$51 749) of the treatment compared with the usual services
provided to men with severe mental illness.96
Interventions for substance use
We identified 2 systematic reviews that reported findings from
6 studies in Vancouver on the cost effectiveness of supervised
consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating
costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of
incident HCV infection.
Providers can, in partnership with directly affected communities,
employ a range of navigation and advocacy tools to address the
root causes of homelessness, which include poverty caused by
inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the
propagation of violence in homes and communities, inadequate
supports for patients and families living with disabilities or going
through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to
the patient’s needs and demographics, taking into account
access to services, personal preferences and other illnesses.152
Providers should also recognize the social and human value
of accepting homeless and vulnerably housed people into their
clinical practices. The following sections provide additional evidence for underserved and marginalized populations.
A scoping review of the literature on interventions for homeless
women (Christine Mathew, Bruyère Research Institute, Ottawa,
Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156
and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused
specifically on homeless and vulnerably housed women. Findings
showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women
with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster
care placements, allowing women to maintain the integrity of their
family unit.158 As well, Housing First programs for families, critical
time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress,
increased self-esteem and improved quality of life for women and
their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among
homeless women. We suggest that providers focus on patient
safety, empowerment among women who have faced genderbased violence, and improve access to resources, including
income, child care and other social support services.
A systematic review on youth-specific interventions reported
findings from 4 systematic reviews and 18 RCTs.162 Permanent
supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in
significant improvements in depression scores, and family-based
therapies are also promising, resulting in reductions in youth
substance use through restoring the family dynamic. Findings on
motivational interviewing, skill building and case-management
interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits.
Refugee and migrant populations
A qualitative systematic review on homeless migrants (Harneel
Kaur, University of Ottawa, Ottawa, Ont.: unpublished data,
2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging
and access to social services, such as housing. However, employment opportunities provided a sense of independence and
improved social integration.
Composition of participating groups
In preparation for the guideline, we formed the Homeless Health
Research Network (https://methods.cochrane.org/equity/
projects/homeless-health-guidelines), composed of clinicians,
academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P.
[chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was
assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario,
Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of
homelessness (herein referred to as “community scholars”180)
were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the
participating groups and monitored competing interests.
The steering committee decided to develop a single guideline
publication informed by a series of 8 systematic reviews. The
ISSUE 10 E247
steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical
topic experts and community scholars who were responsible for
providing contextual expertise.
The steering committee also assembled a technical team,
which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the
responsibility to provide external review of the evidence and
drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists,
psychiatrists, public health professionals, people with lived
experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of
interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/
Selection of priority topics
We used a 3-step modified Delphi consensus method (Esther
Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020) to select priority health conditions for marginalized
populations experiencing homelessness or vulnerable housing.
Briefly, between May and June 2017, we developed and conducted
a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank
and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to
keep in mind 3 priority-setting criteria when considering the
unique challenges of implementing health care for homeless or
vulnerably housed people: value added (i.e., the opportunity for a
unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e.,
the number of people who may have a disease or condition).181
The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care,
delivering care coordination and case management, and facilitating
access to adequate income. The priority marginalized populations
identified included Indigenous people; women and families; youth;
people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère
Research Institute, Ottawa, Ont.: unpublished data, 2020). Each
working group then scoped the literature using Google Scholar and
PubMed to determine a list of interventions and terms relating to
each of the priority-need categories. Each working group came to
consensus on the final list of interventions to be included (Table 3).
We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development
of this clinical guideline, including the identification of clinical
questions, systematic reviews of the best available evidence,
Table 3: Descriptions of priority-need interventions
Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the
provision of individualized supportive services that are tailored to participants’ needs and choices,
including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing
housing) with permanent supportive housing.
Benefits and programs that improve socioeconomic status. This may include assistance that directly
increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and
compensated work therapy) in this category.
Standard case management allows for the provision of an array of social, health care and other services
with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of
services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each
case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental
illness by a multidisciplinary group of health care workers in the community. This team should be available
24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case
management is administered by a critical time intervention worker and is a time-limited service, usually
lasting 6–9 months.
Pharmacologic interventions for
substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine,
diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or
intranasally (e.g., naloxone).
Harm reduction for substance
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use
substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated
alcohol to support residents with severe alcohol use disorder.
assessment of the certainty of the evidence and development of
recommendations.182 We conducted a series of systematic reviews
to answer the following clinical question:
Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions
be considered for people with lived experience of homelessness?
Systematic reviews for each intervention were driven by a logic
model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search
terms, can be found in Appendix 3, available at www.cmaj.ca/
lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and
comparisons according to published a priori protocols.183–186 We
used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The
technical team reviewed titles, abstracts and full texts of identified
citations, selected evidence for inclusion and compiled evidence
reviews, including cost-effectiveness and resource-use data, for
consideration by the guideline panel. The technical team collected
and synthesized data on the following a priori outcomes: housing
stability, mental health, quality of life, substance use, hospital
admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty
of evidence using the GRADE approach. Where pooling of results
was not appropriate, we synthesized results narratively.
In addition to the intervention and cost-effectiveness reviews,
the technical team conducted 3 systematic reviews to collect
contextual and population-specific evidence for the populations
prioritized through our Delphi process (women, youth, refugees
and migrants) (Christine Mathew, Bruyère Research Institute,
Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University
of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally,
we conducted 1 qualitative literature review to capture patient
values and preferences, focused on the experiences of people
who are homeless in engaging with our selected interventions.20
Drafting of recommendations
The steering committee hosted a 2-day knowledge-sharing
event, termed the “Homeless Health Summit,” on Nov. 25–26,
2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all
intervention reviews were presented and discussed according to
the GRADE Evidence to Decision framework.187 After the meeting,
the steering committee drafted GRADE recommendations (Box 2)
through an iterative consensus process. All steering-committee
members participated in multiple rounds of review and revision
of the drafted clinical recommendations.
Guideline panel review
We used the GRADE Evidence to Decision framework to facilitate
the development of recommendations187–189 (Appendix 4, available
We used GRADEpro and the Panel Voice software to obtain input
from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided
considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance
of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off.
Good practice statements
We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A
good practice statement characteristically represents situations in
which a large and compelling body of indirect evidence strongly
supports the net benefit of the recommended action, which is
necessary for health care practice.191–193 Guideline-development
groups consider making good practice statements when they have
high confidence that indirect evidence supports net benefit, there
is a clear and explicit rationale connecting the indirect evidence,
and it would be an onerous and unproductive exercise and thus a
poor use of the group’s limited resources to collect this evidence.
The steering committee came to a consensus on 3 good practice
statements based on indirect evidence.
Identification of implementation considerations
We completed a mixed-methods study to identify determinants
of implementation across Canada for the guideline (Olivia
Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished
data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost
(affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to
implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019;
Gatineau, Que., July 18, 2019) with relevant stakeholders in the
field of homeless health to analyze our implementation data.
Management of competing interests
Competing interests were assessed using a detailed form adapted
from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the
Elsevier sample coauthor agreement form for a scientific project,
contingencies and communication.195 These forms were collected
at the start of the guideline activities for the steering committee,
guideline panel and community scholars. All authors submitted
an updated form in June 2019 and before publication.
The management committee iteratively reviewed these statements and interviewed participants for any clarifications and
concerns. A priori, the management committee had agreed that
major competing interests would lead to dismissal. There were
no competing interests declared.
Our mixed-methods study (Olivia Magwood, Bruyère Research
Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to
implement, identified the following concerns regarding implementation of this guideline.
ISSUE 10 E249
Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to
PSH programs and informing their patients about the resources
available in the community.
The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as
administrative and human resources concerns. For example, not
all primary care providers work in a team-based comprehensive
care model and have access to a social worker or care coordinator
who can help link the patient to existing services. Furthermore,
wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible
Allied health practitioners and physicians do not always agree
with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients
and less experience exploring social determinants of health, such
as housing or income. The initial steps outlined in this guideline
would come at an opportunity cost for them. Stigma attached to
the condition of homelessness was recognized as an important
barrier to care for homeless populations.
Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to
increase the housing supply, income supports and human
resources. However, supervised consumption facilities, with their
range of benefits, were perceived as cost-saving.
Many interventions have the potential to increase health
equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the
initial steps and advocate on a systematic level to increase availability of services.
Suggested performance measures
We developed a set of performance measures to accompany this
guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness
or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for
income assistance over 1 year.
The proportion of eligible adults using opioids who are
offered opioid agonist therapy over 1 year.
The Homeless Health Research Network will be responsible for
updating this guideline every 5 years.
This guideline complements other published guidelines. This
current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous
leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020).
The World Health Organization has developed guidelines to
promote healthy housing standards to save lives, prevent disease
and increase quality of life.196 Other guidelines specific to opioid
use disorder exist,197,198 including 1 for “treatment-refractory”
patients.199 In the United Kingdom, the National Institute for
Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National
Health Care for the Homeless Council in the US has adapted best
practices to support front-line workers caring for homeless
How is this guideline different?
This guideline distills initial steps and evidence-based
approaches, to both homeless and vulnerably housed people,
with the assistance of patients and other stakeholders. It also
introduces a new clinical lens with upstream interventions that
provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the
experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we
hope that our stakeholder engagement inspires and equips
future students, health providers and the public health community to implement the initial step recommendations.
Gaps in knowledge
Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general
housed populations. As primary care expands its medical home
models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in
this guideline. Indeed, clinical research can refine how providers
use the initial steps protocol: housing, income, case management
and addiction. With improved living conditions, care coordination
and continuity of care, research and practice can shift to treatable
conditions, such as HIV and HCV infection, substance use disorder,
mental illness and tuberculosis.203
Medical educators will also need to develop new training
tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many
of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and
case management. Interdisciplinary primary care research and
maintenance of linkages to primary care will benefit from new
homeless health clinic networks. Monitoring transitions in care
and housing availability will be an important research goal for
Canada’s National Housing Strategy and the associated Reaching
Homelessness has become a health emergency. Initial steps in
addressing this crisis proposed in this guideline include strongly
recommending PSH as an urgent intervention. The guideline also
recognizes the trauma, disability, mental illness and stigma
facing people with lived homelessness experience and thus recommends initial steps of income assistance, intensive case management for mental illness, and harm-reduction and addictiontreatment interventions, including access to opioid agonist
therapy and supervised consumption facilities.
The successful implementation of this guideline will depend
on a focus on the initial recommendations, trust, patient safety
and an ongoing collaboration between primary health care,
mental health providers, public health, people with lived experience and broader community organizations, including those
beyond the health care field.
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Group. J Clin Epidemiol 2016;80:3-7.
193. Guyatt GH, Schünemann HJ, Djulbegovic B, et al. Guideline panels should not
GRADE good practice statements. J Clin Epidemiol 2015;68:597-600.
194. Drazen JM, de Leeuw PW, Laine C, et al. Toward more uniform conflict disclosures:
the updated ICMJE conflict of interest reporting form. JAMA 2010;304:212-3.
195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid
publishing conflict and a proposed agreement for co-author teams [editorial].
Biol Conserv 2014;176:277-80.
196. WHO housing and health guidelines. Geneva: World Health Organization; 2018.
197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary
care: PEER simplified guideline. Can Fam Physician 2019;65:321-30.
198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in
Substance Misuse. Management of opioid use disorders: a national clinical
practice guideline. CMAJ 2018;190:E247-57.
199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56.
200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8.
201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www.
homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12).
202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone.
Can Fam Physician 2018;64:170-2.
203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National
Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content
/uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1).
Competing interests: Gary Bloch is a founding member, former board
member and currently a clinician with Inner City Health Associates
(ICHA), a group of physicians working with individuals experiencing
homelessness in Toronto, which provided funding for the development
of this guideline. He did not receive payment for work on the guideline
and did not participate in any ICHA board decision-making relevant to
this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive
payment for any aspect of the submitted work. No other competing interests were declared.
This article has been peer reviewed.
Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie,
d Wendy Muckle led
the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance
use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic
led the review on income, David Ponka and Eric Agbata led the review
on case management, Jean Zhuo Jing Wang and Sebastian Mott led the
homeless youth review, Harneel Kaur led the homeless migrant review,
Christine Mathew and Anne Andermann led the homeless women
review, Syeda Shanza Hashmi and Ammar Saad led medical student
engagement and competency review, Thomas Piggott co-led the GRADE
Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and
Nicole Kozloff contributed substantially to the substance use review,
and Neil Arya and Stephen Hwang provided critical policy information.
All of the named authors engaged in the writing and review, gave final
approval of the version of the guideline to be published, and agreed to
be accountable for all aspects of the work.
Funding: This guideline was supported by a peer-reviewed grant from
the Inner City Health Associates, and supplemental project grants from
the Public Health Agency of Canada, Employment Social Development
Canada, Canadian Medical Association and Champlain Local Integrated
Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the
guideline. The funders had no role in the design or conduct of the study;
collection, analysis and interpretation of the data; or preparation,
review or final approval of the guideline. Final decisions regarding the
protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee.
Acknowledgements: The authors thank everyone who participated in
the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members.
Endorsements: Canadian Medical Association, Canadian Public Health
Association, Canadian Federation of Medical Students, The College of
Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to
End Homelessness, Canadian Nurses Association
Disclaimer: The views expressed herein do not necessarily represent
the views of the funding agencies.
Correspondence to: Kevin Pottie, email@example.com
The Lancet Countdown on Health and Climate Change
Policy brief for Canada
1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the
448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the
Recommendation: Incorporate lessons learned from recent severe wildfire seasons
into a strengthened pan-Canadian emergency response approach that anticipates
increasing impacts as the climate continues to change.
Finding: The percentage of fossil fuels powering transport in Canada remains high, though
electricity and biofuels are gaining ground. Fine particulate air pollution generated by
transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.
Recommendation: Develop provincial and territorial legislation requiring automakers to
gradually increase the annual percentage of new light-duty vehicles sold that are zero
emissions, working toward a target of 100% by 2040.
Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in
the world, with healthcare accounting for approximately 4% of the country’s total emissions.
Recommendation: Establish a sustainable healthcare initiative that assembles experts from
research, education, clinical practice, and policy to support Canada’s healthcare sector in
reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with
healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement,
charting a course for zero-emissions healthcare by 2050.
Finding: The health of Canadians is at risk due to multiple and varied risks of climate
change, including those described in this policy brief (see Figure 1). An ongoing,
coordinated, consistent and pan-Canadian effort to track, report, and create healthy
change is required.
Recommendation: Integrate health considerations into climate-related policymaking
across sectors, including in Canada’s updated 2020 Nationally Determined Contribution
Commitments under the United Nations Framework Convention on Climate Change
(UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share
in achieving the goals of the Paris Agreement.
Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2
“The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era
will come to define the health of an entire generation.”3
However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the
climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path.
Key messages and recommendations
Health and climate change in Canada
Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in
Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie
Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples
outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least
1.5oC as compared to a 1986-2005 reference period.4
Two scenarios are possible for the remainder of the child’s life.
If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as
the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to
1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of
wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as
undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety
and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within
populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This
degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2
Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6),
temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving
Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada
Indicators of climate-related health impacts
This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional
recommendations can also be found in the 2017 and 2018 policy briefs.6,24
Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in
2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more
than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures
not only pose a threat to public health, but also result in major economic and social burdens.
2019 marks a crux point for humanity: choices and policies made in
the lead up to the 2020 UNFCCC Nationally Determined Contribution
submissions will determine whether the world follows the disastrous
high-emissions scenario, or the safer low-emissions path. Children
are taking to the streets to demand a livable world. It is the task of
today’s political leaders and other adults to exert maximal effort
within their spheres of influence in order to set a course for a
healthy response to climate change.
public transit, cycling and walking rates, and adhering to a plantrich
diet in accordance with Canada’s new food guide,
decrease emissions, and also improve health and decrease
Canada is not on track: in 2016, total Canadian GHG emissions were
704 Mt CO2e, an increase of more than 100 Mt since 1990.31
Policies and measures currently under development but not yet
implemented are forecast to reduce national emissions to 592 Mt
CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513
32—a goal which is itself too weak to represent a fair
contribution by Canada to the emissions reductions necessary to
meet the goals of the Paris Climate Change Agreement.
The Earth as a whole is warming less quickly than Canada—but still
far too fast. The IPCC and the World Health Organization have
emphasized that keeping global surface temperature warming to
1.5oC is key to obtaining the best outcomes now possible for human
health.33,34 To do so would require global net human-caused
emissions to fall by about 45% from 2010 by 2030, reaching ‘net
zero’ by 2050.34 Updated Nationally Determined Contributions to
the Paris Agreement are due to be submitted by 2020: policymakers
must integrate health considerations through proposed
Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.*
Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission)
*N.B. Reporting for 2017 only includes evacuations up to and including July
In a mid-range GHG emissions scenario, wildfires in Canada are
projected to rise 75% rise by the end of the 21st century,36
necessitating a strong adaptive response. Human health impacts of
fire include death, trauma, and major burns,37 anxiety during
wildfire periods,35,38 and post-traumatic stress disorder, anxiety
and depression related to evacuations.39,40 Wildfire smoke also
travels vast distances41 and increases asthma and chronic
obstructive pulmonary disease exacerbations, with growing evidence
of an association with all-cause mortality.41 Impacts on health
systems can be severe: during the Fort McMurray fire hospital staff
evacuated 103 patients in a matter of hours,10,42 and the 2017 British
Columbia wildfires resulted in 700+ staff displaced, 880 patients
evacuated, and 19 sites closed by the Interior Health Authority, at a
cost of $2.7 million.12 Such devastating events also generate
significant emissions, contributing to climate change, and helping to
generate conditions conducive to future blazes.43
Much can be done to lessen the health impacts of wildfires.
Qualitative data indicates that populations who are better-briefed
on the local evacuation plan, as well as ways to lessen the risk of fire
to their property, are not only more prepared but also less
anxious.35,38 Building codes can be changed to help keep smoke out,
primary care practitioners can ensure vulnerable patients receive
at-home air filtration systems and respiratory medications prior to
wildfire season,44 public health professionals can collaborate with
municipal officials to maximize smoke forecast-informed outdoor
and well-ventilated indoor recreation opportunities,38 and health
personnel can help ensure evacuation plans are clearly
Sustainable and healthy transport
since 2000, they account for less than 4% of the energy used in
transport (Figure 3). This rate of change is inconsistent with the
emissions pathway required to keep today’s and future children
Support is therefore required for investments in public transit,47
and cycling infrastructure,48 creating win-wins for health by
increasing physical activity levels and improving community
cohesion, while reducing chronic disease, healthcare costs and
GHG emissions.49,50 Zero emissions vehicles also reduce air pollution
and are increasingly affordable: the up-front cost of electric vehicles
is forecast to become competitive on an un-subsidized basis from
2024 onwards.51 British Columbia recently passed legislation
requiring all new cars sold to be zero-emission by 2040.52 Other
provinces would benefit from matching this ambition.
Figure 3: Per Capita Fuel Consumption for Transport in Canada.
Source: Lancet Countdown
Transport-related pollution is harming the health of Canadians. Fine
particulate matter (PM2.5) air pollution related to land-based
transportation was responsible for approximately 1063 deaths in
2015 in Canada, resulting in a loss of economic welfare for
Canadians valued at approximately $8 billion dollars.24 Additionally,
Canada has the highest pediatric asthma rate amongst countries of
comparable income level, with nitrogen dioxide (NO2) from traffic
responsible for approximately 1 in 5 new cases of asthma in
With transport responsible for 24% of national GHG emissions in
2017,31 decarbonizing this sector must be prioritized. Progress is
entirely too slow: total fuel consumption for road transport per
capita decreased 5.4% from 2013 to 2016. While per capita
use of electricity and biofuels for transport increased by 600%
Healthcare sector emissions
Though Canadians are proud of the care they provide for one another
with this country’s system of universal healthcare,53 Lancet Countdown
analysis reveals an area which should give pause to all who endeavor to
“do no harm”: Canada’s healthcare system has the world’s third highest
emissions per capita.
Previous analysis showed healthcare sector emissions to be responsible
for 4.6% of the national total,54 as well as more than 200,000 tons of
other pollutants, resulting in 23,000 disability-adjusted life years (DALYs)
lost annually.54 Emissions from the health sector represent a strategic
mitigation target in a single-payer healthcare system straining under
the weight of an inexorably increasing burden of disease.
While Canadian healthcare sector emissions are increasing, the
world-leading Sustainable Development Unit in England reported an
18.5% decrease in National Health Service, public health and social
care system emissions from 2007-2017 despite an increase in clinical
Despite healthcare being a provincial jurisdiction, there is a role for
pan-Canadian sustainability initiatives to unite diverse experts
spanning public health and the spectrum of clinical disciplines,
economics, sustainability science and beyond. This demands health
sector-wide education, consistent with existing efforts to increase
environmental literacy for health professionals.56
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Residents: Neurotic Disorders, Daily Physician Visits within an Emergency
Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and
Performance Division, Analytics and Performance Reporting Branch,; 2016.
15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation
of the 2013 Alberta flood from weather and climate perspectives. Climate
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lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/
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18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change,
Drought and Human Health in Canada. Int J Environ Res Public Health
19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of
Drought on the Canadian Prairies. EcoHealth 2004.
20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate
Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http://
21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare
for farmers. 2018. Available from: https://www.theglobeandmail.com/
22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al.
Temper-ature-related changes in airborne allergenic pollen abundance and
seasonality across the northern hemisphere: a retrospective data analysis.
Lancet Planet Health 2019;3(3):e124-e31.
23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin
K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017.
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Organisations and acknowledgements
The concept of this brief was developed by the Lancet Countdown on Health
and Climate Change.
This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose,
PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD.
Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman,
Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD;
Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their
Contributions and review on behalf of the Lancet Countdown were provided
by Jess Beagley and Nick Watts, MBBS.
THE LANCET COUNTDOWN
The Lancet Countdown: Tracking Progress on Health and Climate Change is an
international, multi-disciplinary collaboration that exists to monitor the links
between public health and climate change. It brings together 35 academic
institutions and UN agencies from every continent, drawing on the expertise
of climate scientists, engineers, economists, political scientists, public health
professionals, and doctors. Each year, the Lancet Countdown publishes an
annual assessment of the state of climate change and human health, seeking
to provide decision-makers with access to high-quality evidence-based
policy guidance. For the full 2019 assessment, visit www.lancet
THE CANADIAN MEDICAL ASSOCIATION
The Canadian Medical Association (CMA), formed in Quebec City in 1867,
has led some of Canada’s most important health policy changes. As we
look to the future, the CMA will focus on advocating for a healthy population
and a vibrant profession.
THE CANADIAN PUBLIC HEALTH ASSOCIATION
The Canadian Public Health Association (CPHA) is a national, independent,
non-governmental organization that advances public health education,
research, policy and practice in Canada and around the world through the
Canadian Journal of Public Health, position statements, discussion
documents and other resources.
The evolving needs of patients and their communities
place ever-changing demands on the health care system
to maintain and improve the quality of services provided.
Changing population demographics, increasing
complexity, and new technology make for a dynamic
system. Family physicians are at the heart of the health
care system, acting as the first point of contact and a
reliable medical resource to the communities they serve,
caring for patients and supporting them throughout all
interactions with the health care system. The Patient’s
Medical Home (PMH) is a vision that emphasizes the role
of the family practice and family physicians in providing
high-quality, compassionate, and timely care.
The success of a PMH depends on collaboration and
teamwork—from the patient’s participation in their
care to interprofessional and intraprofessional care
providers working together, to policy-makers who can
offer infrastructure support and funding. PMH 2019 was
created with invaluable feedback from a broad range of
stakeholders reflective of such a joint approach. Its goal
is to make the PMH a reality for patients and providers
In 2011 the College of Family Physicians of Canada
(CFPC) released A Vision for Canada: Family Practice -
The Patient’s Medical Home.1 It outlined a vision for the
future of primary care by transforming the health care
system to better meet the needs of everyone living in
Canada. The vision outlined the 10 pillars that make
up the PMH and provided detailed recommendations
to assist family physicians and their teams, as well as
policy-makers and health care system administrators, to
implement this new model across the country.
WHY A REVISED PMH?
Since 2011 many principles of the PMH vision have been
embraced in primary care reforms. New models have
been introduced across Canada (see Progress on the
PMH to Date). To better reflect current realties, meet
the evolving needs of family physicians and their teams,
and support continued implementation of the PMH, the
CFPC has developed this revised edition of the vision.
It reflects evolving realities of primary care in Canada,
including the rapid adoption of electronic medical
records (EMRs)2,3 and a shift toward interprofessional
While progress has been made, there is still work to be done
to fully achieve the PMH vision. In 2016 almost 75 per cent
of Canadians rated the quality of care received from their
family physicians as good or excellent.4 In 2017 a CFPC
survey found that 79 per cent of respondents rate the care
they receive from their family doctor as excellent or good.5
However, at the same time 55 per cent of Canadians also
believed that the overall health care system still required
fundamental changes.4 In addition, Canada continues to
perform below the international average on certain aspects
of patient-centred care; for example, same- or next-day
access to appointments. While most Canadians (84.7 per
cent) have a regular doctor or place of care, they generally
report longer wait times for medical care than adults in
comparable countries.4 PMH 2019 addresses these concerns
and proposes solutions that can help further improve the
primary care system for all.
Although the specific components of the revised PMH have
been updated (see What is the Patient’s Medical Home?),
the core principles remain the same. PMH 2019 focuses on
providing high-quality, patient-centred, and comprehensive
care to patients and their families during their lifetime. It
embraces the critical role that family physicians and family
practices play in the health care system, reflecting the fact
that systems with strong primary health care deliver better
health outcomes, enhance efficiency, and improve quality of
care.6 PMH 2019 recognizes that a patient will not be able
to see their personal family physician at every visit, but can
rely on the PMH’s qualified team of health professionals to
provide the most appropriate care responding to patient
needs with continuous support and leadership from family
physicians. PMH 2019 highlights the central importance
of community adaptiveness and social accountability in
primary care with a new pillar. The importance of being
responsive to community needs through engagement, and
ensuring the provision of equitable, culturally safe, antioppressive
practise that seeks to assess and intervene into
social determinants of health (SDoH), is now more clearly
2 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PURPOSE OF THIS DOCUMENT
PMH 2019 outlines 10 revised pillars that make up a
PMH. Key attributes are defined and explained for each
pillar. Supporting research is provided to demonstrate
the evidence base for each attribute. This document
is intended to support family physicians currently
working in a PMH to better align their practice with
the PMH pillars, or assist those practices looking to
transition to a PMH. Furthermore, this document can
guide governments, policy-makers, other health care
professionals, and patients on how to structure a primary
health care system that is best-suited to meet the needs
Many resources for the PMH have been developed and
will continue to be available. These include practical Best
Advice guides on a range of topics and the self-assessment
tool that can help quantify a practice’s progress toward
PMH alignment. Moving forward, additional materials
that address the new themes identified in PMH 2019 and
the tools to support physicians in the transition to PMH
structures—for example the PMH Implementation Kit—
will be available at patientsmedicalhome.ca.
What is a Patient’s Medical Home?
The PMH is a family practice defined by its patients
as the place they feel most comfortable presenting
and discussing their personal and family health and
medical concerns. The PMH can be broken down into
three themes: Foundations, Functions, and Ongoing
Development (see Table 1 and Figure 1).
The three Foundation pillars are the supporting structures
that facilitate the care provided by the PMH. All three
aspects are required for the successful implementation
and sustainability of a PMH.
The Functions are areas central to the operation of a family
practice and consist of the five core PMH pillars. These
principles govern the type of care provided by the PMH
practices to ensure it is effective and efficient for meeting
the needs of the patients, families, and communities they
serve. The pillars in this section reflect the Four Principles
of Family Medicine,7 which underlines the important
place they take in the overall PMH 2019.
The pillars in Ongoing Development are essential to
advancing the PMH vision. These areas make it possible
for physicians to provide the best possible care for
patients in various settings. Applying these pillars, the
PMH will thrive through practising quality improvement
(QI) principles to achieve the results necessary to meet
the needs of their patients, their communities, and the
broader health care community, now and in the future.
The PMH is a vision to which every practice can aspire.
Many practices across Canada have already begun
transitioning to a PMH, thanks to the dedication and
leadership of family physicians and their teams across
Table 1. 10 Pillars of the revised PMH vision
1. Administration and Funding
2. Appropriate Infrastructure
3. Connected Care
4. Accessible Care
5. Community Adaptiveness and Social Accountability
6. Comprehensive Team-Based Care with Family Physician Leadership
7. Continuity of Care
8. Patient- and Family-Partnered Care
9. Measurement, Continuous Quality Improvement, and Research
10. Training, Education, and Continuing Professional Development
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 3
the country. This vision is a resource for these practices
as they engage in ongoing practice assessment and QI
initiatives. It can also assist other stakeholders, including
government planners, policy-makers, and funders to
better understand what defines an effective patientcentred
family practice. By involving patients in all stages
of the development, evaluation, and continuous quality
improvement (CQI) activities of the practice, the PMH
can contribute significantly to furthering the goals of
transformation to a patient-centred health care system.8
What the Patient’s Medical Home is Not
While it is important to understand what the PMH
aspires to be, it is also important to highlight that it is
not a one-size-fits-all solution. Solo practices in rural
or remote settings or large group practices serving
inner-city populations can align with PMH principles
by incorporating strategies that match the realities of
their unique settings. In fact, social accountability and
community adaptiveness is an important new addition
to the revised PMH vision to account for the need of
every family practice to adapt and respond to the needs
of their patients and communities. What works for one
practice will not work for all.
The PMH vision does not require that all practices be
relocated or re-engineered, or that significant financial
investments be made by physicians or other health
care professionals. Instead, system level support and
involvement is required to achieve the vision. The pillars
and attributes listed in this document are signposts along
the way to reform that aids practices on their journey.
It is important to note that this vision is not intended to
undermine or change any exciting initiatives involving
family practice currently under way across Canada
(several of which already embrace and incorporate
the medical home concept; see Progress on the PMH
to Date). Rather, it is meant to build on and strengthen
these efforts. The more that health care initiatives meet
PMH objectives, the more likely it is that the overall
goals of creating a patient-centred health care system
throughout Canada will be realized.
Figure 1. The Patient’s Medical Home
4 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PROGRESS ON THE PMH TO DATE
Since the release of the original PMH vision document,
system-level change has occurred in almost all
jurisdictions in Canada. More specifically, PMH-type
practices are gaining traction in various provinces and
currently exist in various stages of development.
The CFPC took a snapshot of PMH uptake in all provinces
in the PMH Provincial Report Card, published in early
2019.9 That report contains grades and descriptions for
progress in each province up to late 2018, which acts as
a useful gauge for where the vision stands at the time of
publication of this new edition.
In Alberta, primary care networks (PCNs)10 were
established to link groups of family physicians and other
health care professionals. Within PCNs clinicians work
together to provide care specific to community and
population health care needs. Currently, there are 42 PCNs
operating in Alberta, comprised of more than 3,700 (or 80
per cent of) family physicians, and over 1,100 other health
care practitioners. PCNs provide care to close to 3.6 million
Albertans, 80 per cent of the population in Alberta.
Primary care clinics are being asked to collect data for
Third Next Available (TNA) appointments to improve
access for Albertans.11 TNA measures the delay patients
experience in accessing their providers for a scheduled
appointment. TNA is considered a more accurate system
measure of access than the “next available” appointment,
since the next or second next available appointment may
have become available due to a cancellation or other
event that is not predictable or reliable.
The British Columbia government’s new primary care
strategy focuses on expanding access to team-based
care through PCNs.12 PCNs are in the initial stages of
adoption and when fully rolled out will provide a systemlevel
change—working to connect various providers to
improve access to, and quality of, care. They will allow
patients to access the full range of health care options,
streamline referrals, and provide better support to
family physicians, nurse practitioners, and other primary
health care providers. The General Practice Services
Committee13 (GPSC; a partnership of the provincial
government and Doctors of BC) specifically references
and builds on the PMH concept in their vision for the
future of British Columbia’s health care system.
In Manitoba, PMHs are Home Clinics and PCNs are My
Health Teams. My Health Teams bring together teams
of health care providers (physicians, nurses, nurse
practitioners, etc.) to collaborate in providing highquality
care based on community and patient needs.14 As
suggested by the name of the initiative itself, the goal
is to improve health care by developing teams of health
care professionals who will work together to address
primary health care needs of Manitobans.15 The first two
My Health Teams were established in 2014, and there are
now 15 across the province.16 The Manitoba Centre for
Health Policy did some work assessing the impact of My
In 2017 the government announced the New Brunswick
Family Plan, which placed a specific emphasis on access
to team-based care. To achieve this goal, the provincial
government and the New Brunswick Medical Society
established a voluntary program called Family Medicine
New Brunswick. In this team-based model, physicians
have their own rosters of patients, but also provide a
service to all patients of doctors on their team.17 It was
announced in 2018 that 25 family physicians will be
added to the provincial health care system to ensure
more New Brunswick residents have access to a primary
care physician and to help reduce wait times.18
Newfoundland and Labrador
In 2015 the Newfoundland and Labrador government
released Healthy People, Healthy Families, Healthy
Communities: A primary health care framework for
Newfoundland and Labrador. The strategy’s goals
include ensuring “timely access to comprehensive,
person-focused primary health care services and
supports,” and “primary health care reform should work
to establish teams of providers that facilitate access to
a range of health and social services tailored to meet
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 5
the needs of the communities they serve.”19 Both goals
align with the general PMH principles. Primary health
care teams have been introduced in St. John’s and are
planned for Corner Brook and Burin.20 Many initiatives
under way as a part of this strategy are in the early stages
of development. Continuing in the direction laid out will
move Newfoundland and Labrador closer to integrating
the PMH vision in their delivery of primary health care.
The recent creation of a single Territorial Health Authority
has enabled work on primary care improvements across
the Northwest Territories. In August 2018 the NWT Health
and Social Services Leadership Council unanimously
voted in favour of a resolution supporting redesigning
the health care system toward a team- and relationshipbased
approach, consistent with PMH values. In several
regions, contracted physicians are already assigned to
regularly visit remote communities and work closely
with local staff to provide continuity of remote support
between visits. Planning is under way for implementing
PMH-based multidisciplinary care teams in several larger
regional centres, with enhanced continuity and access to
physician and nursing staff as well as co-located mental
health support and other health care disciplines. This
work is facilitated by a territory-wide EMR and increased
use of telehealth and other modalities of virtual care.
The 2017 Strengthening the Primary Health Care
System in Nova Scotia report recommended establishing
“health homes,” consisting of interprofessional,
collaborative family practice teams. The model is based
on a population health approach that focuses on wellness
and chronic disease management/prevention and
incorporates comprehensive, team-based care. There are
approximately 50 collaborative family practice21 teams
and a number of primary care teams across Nova Scotia.
The model most aligned with the PMH framework is the
family health team (FHT).22 FHTs are comprised of family
physicians, nurse practitioners, and other health care
professionals, and provide community-centred primary care
programs and services. The 184 FHTs collectively serve over
three million enrolled Ontarians. Based on the results of a
five-year evaluation undertaken by the Conference Board
of Canada in 2014, FHTs have achieved improvements
at the organizational and service-delivery levels.23 Much
progress has also been made through patient enrolment
models. Patient enrolment, or rostering, is a process in
which patients are formally registered with a primary
care provider or team. Patient enrolment facilitates
accountability by defining the population for which the
provider is responsible. Formal patient enrolment with a
primary care physician lays the foundation for a proactive
approach to chronic disease management and preventive
care.24 Studies show that the models have achieved some
degree of success in enhancing health system efficiency
in Ontario through the reducing use of emergency
departments for non-emergent care.25
Prince Edward Island
In Prince Edward Island, primary care is provided
through five PCNs.26 Each network consists of a team
that includes family physicians, nurse practitioners,
registered nurses, diabetes educators, licensed practical
nurses, clerical staff, and in some cases dietitians and
mental health workers. They offer a broad range of
health services including diagnosis, treatment, education,
disease prevention, and screening.
The Groupes de médecine de famille27 (GMF) is the
team-based care model in Quebec most closely aligned
with the PMH. GMF ranking (obligations, financial, and
professional supports) is based on weighted patient
rostering. One GMF may serve from 6,000 to more than
30,000 patients. The resource allocation (financial and
health care professionals) depends on the weighted
patient target under which the GMF falls. In a GMF,
each doctor takes care of their own registered patients,
but all physicians in the GMF can access medical
records of all patients. GMFs provide team-based care
with physicians, nurses, social workers, and other health
care professionals working collaboratively to provide
appropriate health care based on community needs.
Saskatchewan has made investments in a Connected
Care Strategy, which focuses on a team approach to
care that includes the patient and family, and extends
from the community to the hospital and back again. It is
about connecting teams and providing seamless care for
people who have multiple, ongoing health care needs,
with a particular focus on care in the community.28
6 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing
each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred
care. The foundations are Administration and Funding (includes financial and governmental support and strong
governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources,
and electronic records and other digital supports), and Connected Care (practice integration with other care settings
enabled by health IT).
Patients as partners in health care
Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a
small but powerful change in terminology. Considering and respecting patients as partners allows health care providers
to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and
feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding
the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29
Pillar 1: Administration and Funding
Practice governance and management
Effective practice governance is essential to ensuring
an integrated process of planning, coordinating,
implementing, and evaluating.30 Every PMH should
clearly define its governance and administrative structure
and functions, and identify staff responsible for each
function. While the complexity of these systems varies
depending on the practice size, the number of members
on the health care professional team, and the needs of
the population being served, every PMH should have an
organizational plan in place that helps guide the practice
From a governance perspective, policies and procedures
should be developed and regularly reviewed and
updated, especially in larger practices. These policies
and procedures will offer guidance in areas such as
organization of clinical services, appointment and
booking systems, information management, facilities,
equipment and supplies, human resources, defining PMH
team members’ clinical and administrative/management
roles and responsibilities, budget and finances, legal
and liability issues, patient and provider safety, and
CQI. In some cases, standardized defaults for these
may be available based on the province of practice and
existing structures supporting interprofessional teams.
Structures and systems need to be in place that allow
for compensated time for providers to undertake and
actively participate in CQI activities. This needs to be
scheduled and remunerated so that it is seen as being as
important and critical as clinical time.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient government funding to cover training
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 7
Practices need staff and financial support, advocacy, governance, leadership, and management in
order to function as part of the community and deliver exceptional care.
1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in
1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and
administrative roles of all members of PMH teams.
1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be
considered to incentivize the desired approach.
1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms
that support PMH priorities, including preventive care, population health, electronic records, community-based
care, and access to medications, social services, and appropriate specialist and acute care.
8 A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019
costs and financial support to ensure lost income is not a
barrier (see Pillar 10: Training, Education, and Continuing
Every family practice in Canada can become a PMH
and an optimal learning environment will only be
achievable with the participation and support of all
stakeholders throughout the health care system. This
includes family physicians; other health professionals
who will play critical roles on PMH teams; federal,
provincial, and territorial governments; academic
training programs; governing bodies for physicians
and allied health care providers; and most importantly,
the people of Canada themselves, individually and in
their communities—the recipients of care provided by
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Given that
the structure, composition, and organization of each
PMH will differ based on community and population
needs, funding must be flexible. More specifically,
PMH practices will differ in terms of the staff they
require (clinical, administrative, etc.). Funding must
be available to ensure that PMH practices can
determine optimal staffing levels and needs, to best
meet community needs. The health care system must
also ensure that all health care professionals on the
PMH team have appropriate liability protection, and
that adequate resources are provided to ensure that
each PMH practice can provide an optimal setting for
teaching students and residents and for conducting
practice-based research. These characteristics
are also reflected in the Four Principles of Family
Medicine, reinforcing the centrality of family medicine
to the delivery of care.
Experience through new models of family practice,
such as patient enrolment models (PEMs) in Ontario,
suggests that blended funding models are emerging as
the preferred approach to paying family physicians.31–33
These models are best suited to incentivizing teambased,
patient-partnered care. The current fee-forservice
(FFS) model incentivizes a series of short
consultations that might be insufficient to address all
of the patient’s needs, while blended remuneration
provides for groups of physicians to work together to
provide comprehensive care through office hours and
after-hours care for their rostered patients. Capitation
allows for more in-depth consultations depending on
population need, rather than a volume-based model.
Research has also found that blended capitation models
can lead to small improvements in processes of care
(e.g., meeting preventive care quality targets)34 and can
be especially useful for supporting patients in managing
and preventing chronic diseases.35 The CFPC advocates
for governments to implement blended payment
mechanisms across the country to achieve better
health outcomes (see the Best Advice guide: Physician
Remuneration in a Patient’s Medical Home36 for more
It is important to ensure that additional practice activities
such as leadership development, QI, and teaching are
supported through dedicated funding or protected time
intended specifically for these activities and are not
seen as financially disadvantageous.
The sustainability of Canada’s health care system
depends on a foundation of strong primary care and
family practice.37 Indeed, “high-performing primary care
is widely recognized as the foundation of an effective and
efficient health care system.”38 Future funding for health
care—in particular from the federal government through
federal, provincial, and territorial agreements—must
be sustained through appropriate and well-designed
funding agreements that incentivize PMH visions of
primary care; other medical home priorities including
preventive care, population health, EMRs; communitybased
care; along with access to medications, social
services, and appropriate specialist and acute care.
For the PMH vision to be successful and a part of the
future of family practice care in Canada, we need the
commitment and support of everyone in the Canadian
health care system, including decision makers and
patients. By working with all levels of government and
with patients, we can improve the health care system so
that everyone in Canada has access to patient-centred,
comprehensive, team-based care.
A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 9
Pillar 2: Appropriate Infrastructure
The shift in Canada from paper-based patient records
to EMRs is reaching saturation. As delivery of care
evolves with greater integration of technology, potential
applications to improve patient care expand.39 The
proportion of family physicians using EMRs has grown
from 16 per cent in 2004 to 85 per cent in 2017.40
As it becomes ubiquitous in health care delivery,
information technology can be of great benefit in
sharing information with patients, facilitating adherence
to treatment plans and medication regimes, and
using health information technology (HIT) in new and
innovative methods of care. However, HIT also poses new
risks and can create new barriers. Providers should be
mindful of how the application about new technologies
may hinder good quality patient care.
When properly implemented, EMRs can help track data
over time, identify patients who are due for preventive
visits, better monitor patient baseline parameters (such
as vaccinations and blood pressure readings), and
improve overall quality of care in a practice.1 EMRs can
enhance the capacity of every practice to store and recall
medical information on each patient and on the practice
population as a whole. They can facilitate sharing
information needed for referrals and consultations.
The information in an electronic record can be used
for teaching, carrying out practice-based research, and
evaluating the effectiveness of the practice change as
part of a commitment to CQI.1 EMRs and HIT actively
support other pillars in the PMH vision.
In addition to storing and sharing information, the
biggest benefit of this technology is the ability to
collect data for practice performance and health
outcomes of patients served by family practices.41 The
data allow practices to measure progress through
CQI goals. Larger-scale collection allows for the
aggregation of anonymized data sets and measuring
performance beyond the practice level.41 Strict privacy
regulations ensure that patient data remain secure
and confidential. Overall, QI and research benefit
patients by guiding more appropriate and efficient
care, which forms the basis of another key pillar of
Physical space, staffing, electronic records and other digital supports, equipment, and virtual
networks facilitate the delivery of timely, accessible, and comprehensive care.
2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems.
2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes
family physicians and other health care professionals. Practices are able to select an EMR product from a list
of regionally approved vendors.
2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary
care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools;
e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research,
evaluation, and CQI.
2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable.
2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and
interaction between team members.
2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered
nurses to meet PMH goals).
2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare.
2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements
will be met by every PMH teaching site.
the PMH vision— Pillar 9: Measurement, Continuous
Quality Improvement, and Research.
As EMR use becomes common, issues shift from rollout
to optimization in the practice. Ideally, EMRs must
be adequately supported financially and use a universal
terminology to allow for standardized data management,
and be interoperable with other electronic health
records relevant to patient care.1 Training and ongoing
technical support for effective use of technology must
also be available. Digital information sources, especially
in the sensitive areas of patient information and care
planning, require a higher level of technical support
to maintain faith in their use and application across
A comprehensive, systematic analysis of peer-reviewed
and grey literature found that cost sharing or financial
sponsorship from governments is required to support the
high cost of EMR adoption and maintenance. Governments
in several European countries equip all primary care
practices with interoperable, ambulatory care-focused
electronic health records (EHRs) that allow information
to flow across settings to enhance the continuity
and coordination of care.1 Ensuring that government
supports enable adoption, maintenance and effective use,
coordination, and interoperability of electronic tools is
crucial for meaningful use of this technology.
A PMH will also use technology for alternative forms
of care. Virtual care is clinical interactions that do not
require patients and providers to be in the same room
at the same time.42 Virtual visits will be financially
compensated by provincial health plans. Consultations
may be asynchronous, where patients answer structured
clinical questions online and then receive care from a
physician at a later time (e-visits), or synchronous,
where patients interact with physicians in real time via
telephone (teleconsultations), videoconference (virtual
visits), or text.43 Virtual care increases accessibility
for those living in rural and remote areas, but also in
urban areas where some patients do not have a regular
primary care physician or cannot access their physician
for in-person appointments within a time frame that
meets their current needs.43 Virtual care can also be an
alternative solution for patients living in long-term care
facilities and/or with mobility issues.43
Strong communication between team members allows
PMH practices to function on a virtual basis when the
health care professionals are not stationed in the same
physical space. It is important to recognize when colocation
is not feasible and maintain effective information
flow in these situations, which may be especially relevant
in rural and remote areas.
Practices should ensure the electronic records they
use are set up to support collaboration and interaction
between all members of the team as much as possible,
which includes all health care providers within the PMH
as well as the patient’s circle of support. For example,
ensuring that when patients see someone other than
their most responsible provider is logged into the
system and is easy to review to maintain the continuity
of care. This becomes complex in situations where
providers are not co-located, and further system level
supports up to the level of more interoperable and
universal electronic records is a prerequisite for full
application of this principle.
Appropriate infrastructure in a PMH is not just
about technology—it includes efficient, effective, and
ergonomically well-designed reception, administration,
and clinical areas in the office. This is of significant
benefit to staff and patients alike.44 Having a shared
physical and/or virtual space where multiple team
members can meet to build relationships and trust,
and communicate with each other regarding patient
care is essential to creating a collaborative practice.
Team-based care thrives when care is intentional,
when planned and regular patient care meetings are
incorporated into usual PMH practice, and when these
steps are included in remuneration. This collaboration
ensures that patients are involved in all relevant
Satisfaction with virtual visits
A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of
high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their
10 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
The Patient’s Medical Home 2019 11
discussions and are receiving the best care from
professionals with a comprehensive set of skills.
A family practice should be physically accessible to
patients and their families. This includes ensuring all
public areas, washrooms, and offices are wheelchair
accessible.44 An examination room should comfortably
accommodate the patient and whatever appropriate
companion, or health care professionals, who may be
in the room at the same time. Having multi-purpose
rooms also reduces or eliminates the need to wait for an
appropriate room to be available.
To achieve their objectives, PMHs need the support
of governments across Canada through the provision
of adequate funding and other resources. Research
demonstrates that in the case of EMRs, key barriers
to adoption by family physicians include financial
and time constraints, lack of knowledgeable support
personnel, lack of interoperability with hospital and
pharmacy systems,45 as well as provincial/territorial EHR
systems. Therefore, government must assure funding
to support the PMH team in their clinical, research,
and administrative responsibilities. There must also be
support for core practice components such as EMRs,
patient-centred practice strategies such as group visits,
and electronic communications between patients and
health professionals (see Pillar 1: Administration and
Funding). EMRs should help improve the delivery of care
in community-based practices by enhancing productivity
and processes. They are not intended to reduce time
with patients, nor should they cause physician burnout
or have a negative impact on physician wellness. While
the structures supporting the PMH practices differs by
province, it is important they cover a common set of
principles enabling the base functionalities described in
this document. The system must also ensure that all health
professionals on the PMH team have appropriate liability
protection and that adequate resources are provided so
that each PMH practice can provide an optimal setting
for teaching students and residents and for conducting
practice-based research. Provider autonomy is critical
to provider wellness: as physician leadership within the
PMH is one of the key pillars, preservation of physician
autonomy, while respecting the autonomy and ensuring
the accountability of both patients and other health care
professionals, must be addressed.
Figure 2. The Patient’s Medical Neighbourhood
Pillar 3: Connected Care
Canada Health Infoway
Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal
government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative
strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada.
Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals.
Connectivity and effective communication within and
across settings of care is a crucial concept of a PMH.
This ensures that the care patients receive is coordinated
and continuous. To achieve this, each PMH should
establish, maintain, and use defined links with secondary
and tertiary care providers, including local hospitals;
other specialists and medical care clinics; public health
units; and laboratory, diagnostic imaging, physiotherapy,
mental health and addiction, rehabilitation, and other
health and social services.
Connected care is a priority for many health care
organizations in Canada. For example, the Canadian
Foundation for Healthcare Improvement (CFHI) has
established a unique program that looks at improving
care connections between providers through improved
use of technology.41 (See the Canadian Foundation for
Healthcare Improvement textbox for more information).
The Canadian Nurses Association (CNA), Canadian
Medical Association (CMA), and HEAL recognize
that giving Canadians the best health and health care
requires creating a functionally integrated health
system along the full continuum of care—a system
based on interprofessional collaborative teams that
ensure the right provider, at the right time, in the right
place, for the right care.46 Similarly, Canada Health
Infoway focuses on expanding digital health across the
system to improve quality of and access to care.
The PMH exists within the broader patient’s medical
neighbourhood (see Figure 2), with links to all other
providers in the community. It is important to maintain
connections with colleagues in health care as well as
social support organizations within the community, as
described in Pillar 5: Community Adaptiveness and
Through links within the neighbourhood, PMH practices
work with other providers to ensure timely access
for referrals/consultations and define processes for
information sharing. Establishing and maintaining
these links requires open and frequent communication
between all those involved in patient care.
12 A NEW VISION FOR CANADA Family Practice—
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Practice integration with other care settings and services, a process enabled by integrating health
3.1 A PMH is connected with the health and social services available in the community for patient referrals.
3.2 Defined links are established between the PMH and other medical specialists, and medical care services in
the local or nearest community to ensure timely referrals.
3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information
technology. It ensures the continuity of patient information received throughout the medical and social
Ideally PMH practices act as the central hub for patient
care by collecting and coordinating relevant patient
information from external care providers and patients.
This includes medical care and care accessed through
other health and social services; for example, services
received through home care programs. PMH practices
should also be able to share relevant information with
external providers where and when appropriate, while
strictly adhering to relevant privacy regulations. This
two-way flow of information ensures that all providers in
the network of care have access to the most accurate
and comprehensive information available, allowing them
“… to spend less time looking for information and more
time on what matters: treating the patient.” 49
Overall, connected care in the PMH and the health
system is enabled through HIT systems. PMH practices
continuously strive to work efficiently with other
providers in the patient’s medical neighborhood by
taking advantage of developing technologies that make
links quicker to establish and easier to maintain.
To use HIT systems for coordinated care, the following
Interoperable EMR and other health information
Real-time access to data and the ability to relay
accurate information in a timely manner
Reliable communication mechanisms between
various health and social service providers and the
Privacy for patient information
It is important to keep in mind that any patient information, generated during the provision of care,
belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act
(PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information.
Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of
EMRs50 for more information.
Canadian Foundation for Healthcare Improvement
The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative
Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with
specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait
times for accessing specialty care by enabling family physicians to more efficiently manage their patients in
primary care settings.
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14 A NEW VISION FOR CANADA Family Practice—
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The functions describe the heart of the PMH and the care provided by PMH practices. These are the key
elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community
Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership;
Continuity of Care; and Patient- and Family-Partnered Care.
COMMUNITY ADAPTIVENESS &
CARE WITH FAMILY PHYSICIAN
CONTINUITY OF CARE
PATIENT & FAMILY PARTNERED CARE
Equitable and ethical practices
The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly,
accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54
Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the
CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices
in health care and public health.55
Pillar 4: Accessible Care
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Accessible primary care is fundamental to a highperforming
health care system and is considered by
patients52 and other health care organizations as one
of the most important characteristics of primary health
care. For care to be accessible, all patients should have
access to a family physician who acts as their most
responsible provider and is supported by a team of
qualified health professionals. Patients must be able
to access medical care and treatment when needed.
While most Canadians currently have a regular family
doctor,4 it is important that the goal be for everyone in
Canada to have access to their own family physicians.
Accessible care is about more than just quick access to
appointments. It does include timely access principles,
but also advanced access, virtual access, and teambased
approaches to care that ensure patients can be
seen by the most appropriate provider when they need
to be seen.
Because visits occur for different reasons it is not useful
to define appropriate wait times for each type of visit
unlike in other areas of health care, such as surgery.
Therefore, the focus in family practice should be on
enhancing access to ensure patients can access care
when they feel it is necessary. This is not to say that
family physicians in a PMH must be on call 24/7/365,
but that methods for patients to access care through
the design of practice operations and scheduling
should be given more attention. On the other hand,
as patients are offered more choice (e.g., by phone or
e-communication), they should also expect practices
to establish realistic parameters for what is reasonable.
Practices should communicate clearly about what kind of
provider availability and response time is reasonable to
expect depending on access method and availability of
resources. Obtaining this understanding from a practice’s
patients and striving to meet these expectations is a
By adopting advanced and timely access, virtual access, and team-based approaches, accessible
care ensures that patients can be seen quickly.
4.1 A PMH ensures patients have access to medical advice, and information on available care options 24
hours a day, 7 days a week, 365 days a year.
4.2 Every patient is registered with a PMH.
4.3 PMH practices offer scheduling options that ensure timely access to appropriate care.
4.4 When the patient’s personal family physician is unavailable, appointments are made with another
physician, nurse, or other qualified health professional member of the PMH team.
4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking
4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and
safe, high-quality care.
A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services
from other health care providers seen as a key for improving patient access.59
Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment
and also consults another provider in the interim), improves health outcomes, leads to better patient and provider
satisfaction, and reduces emergency visits.56–58
16 A NEW VISION FOR CANADA Family Practice—
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good way to maintain the patient-centred focus of the
practice as described in Pillar 1: Administration and
Funding. Significant shifts in providing alternative access
must be supported by funding bodies.
Same-day scheduling has been introduced in many
PMH practices to better accommodate patient needs.
Frequently referred to as doing “today’s work today,”
advanced access offers the vast majority of patients the
opportunity to book their appointments on the day they
call regardless of the reason for the visit.60 Read more
about same day scheduling in the Best Advice guide:
Timely Access to Appointments in Family Practice.61
Whenever possible, patients should have clear reasons
for the appointment at the time of booking. This ensures
that adequate time is planned for each patient visit. If
the need to address multiple problems arises, the
problems can be triaged on the spot by one of the team
and arrangements made to have these concerns dealt
with in a timely manner either during the same visit or at
It is not always possible for patients to book appointments
with their most responsible family physician. To ensure
continuity, appointments can be made with other
physicians or health care professionals in the team. The
decision about who provides care in these cases is based
on the patient’s needs, the availability of team members,
and the scope of practice for each team member. In these
cases, any relevant information from the appointment
is communicated to the most responsible provider and
taken into account in the long-term care of the patient.
PMH practices can further meet patients’ needs through
extended office hours, in which the responsibilities for
coverage and care are shared by family physicians in one
or more practices, as well as by increased involvement of
other team members. PMH practices also provide their
patients with email, after-hours telephone, and virtual
services to guide them to the right place at the right
time for the care they need. Appropriately directing
patients to the next available appointment, or to a
hospital or another emergency service, is critical to the
effective management and sustainability of our health
care system.62,63 A PMH can help ensure that patients
are aware of where they can go to access care and
health information 24 hours a day, 365 days a year by
providing this information to patients in person or via
other systems (website, voice mail messages, etc.).
In alignment with Pillar 9: Measurement, Continuous
Quality Improvement, and Research, PMH practices offer
opportunities for patients to provide feedback on the
accessibility of the practice. Specifically, patients should
have the opportunity to evaluate and provide input for the
appointment booking system. Mechanisms and supports
need to be in place to ensure that practices and governing
bodies can review and respond to feedback appropriately
and communicate this back to patients.
Determining the optimal panel size for each PMH practice
is critical to ensuring accessible and safe, high-quality
care.64 Establishing and incorporating recommendations
from the PMH vision may enable practices to consider
increasing their panel size. Actual panel size will vary
depending on the number of physicians and other team
members in the practice, the practice’s obligations and
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Social accountability refers to the family physicians’
obligation to meet the needs of Canada’s
communities.66 For health care to be socially
accountable, it must be accessible by everyone and
responsive to the needs of patients, communities, and
the broader population.4 This obligation is embedded
in the Family Medicine Professional Profile and the
Four Principles of Family Medicine, highlighting that
family physicians are community-adaptive, responding
to the needs of their patients and communities.
These principles of family medicine align well with
the principles of social accountability. Family practice
is relationship-based care that embraces all issues
of need and endures over time and place of care. A
generalist keeps the whole in mind while attending
to the individual parts, the system in mind when
fixing individual problems, and the end in mind
when commencing the journey. Tools exist to help
family physicians and other health care providers
enhance their skills and training regarding social
accountability and cultural safety through many
professional organizations and cross-Canada
resource hubs like the National Collaborating
Centre of Determinants of Health67 and the National
Collaborating Centre on Aboriginal Health,68 as
PMH practices are aware of how the SDoH influence the
health of patients and communities. Family physicians are
often the best-situated primary care professionals to act on
Pillar 5: Community Adaptiveness and Social Accountability
A PMH is accountable to its community, and meets their needs through interventions at the patient,
practice, community, and policy level.
5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing,
immigration status) as relevant for the individual, community, and policy levels.
5.2 Panel size will consider the community’s needs and patients’ safety.
5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to
meet unique community needs.
Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using
the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in
Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe,
seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender,
race, class, sexual orientation, gender identity, ability, etc.
commitment to teaching and research, and the needs
of the population being served (see Pillar 5: Community
Adaptiveness and Social Accountability). When deciding
panel size, each practice must determine how accepting
more patients into the practice might impact the
current population, the sustainability of the workload for
physicians and other members of the PMH team, and
the consequences of panel size on experience of care.
Refer to the Best Advice guide: Panel Size for more
issues that affect patients’ SDoH. Advocating for patients
and the health care system overall is a natural part of a
PMH structure. Advocacy can occur at three levels:69
Micro: In the immediate clinical environment, daily
work with individual patients and predicated on
the principles of caring and compassion
Meso: In the local community, including the
patient’s cultural community, the local community
of medical providers, and the larger civic
community, in which health professionals are
citizens as well as practitioners
Macro: In the humanitarian realm, where physicians
are concerned with the welfare of their entire
patient population and seek to improve human
welfare through healthy public policy (such as
reducing income inequality, supporting equitable
and progressive taxation, and expanding the
social safety net)
The principles of advocacy in family practice are found
in the CanMEDS–Family Medicine 201769 competency
framework, under the Health Advocate role. The
Best Advice guide: Social Determinants of Health70
describes how family physicians in the PMH can make
advocacy a practical part of their practice.
Poverty is a significant risk factor for chronic disease,
mental illness, and other health conditions. Low income
and other SDoH also present significant barriers to
accessing care.71 To meet the needs of these patients,
practices may need to extend hours, be more flexible
and responsive, and spend additional time helping
patients navigate and access necessary care. PMH
practices consider other specific community needs when
determining appropriate panel size. Demographics and
health status of the patient population can influence the
length and frequency of appointments needed, thereby
impacting a physician’s caseload.65 For example, a PMH
in a community with high rates of chronic conditions
may need to reduce the panel size to provide timely and
high-quality care, given that patients require more care
time and resources. Similarly, a patient’s social situation
may impact the time a family physician spends with
them. Family physicians and team members may need to
use a translator at clinical appointments, and may need
to provide written resources in alternative languages,
all factors affecting the time required to provide care.
Enabling PMH practices to adjust panel size based on
community needs requires governments to establish
blended payment mechanisms. These remuneration
systems ensure family physicians are adequately
compensated, and are not financially disincentivized from
spending the necessary time with patients (see Pillar 1:
Administration and Funding, for more information).
Social accountability and cultural competency
Part of the response to being more socially accountable with care offered to the community resides within each
and every health professional. While courses on cultural competency are now a standard part of medical education,
physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases
that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is
a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the
satisfaction of being an effective healer—of ourselves, our patients and our societies.
Importance of social accountability
Social accountability is a key value for health care organizations and professionals. For example, the Royal College
of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of
Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability
within their organizations and the work they do.
18 A NEW VISION FOR CANADA Family Practice—
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Family physicians and their PMH teams are situated
at the nexus of individual and population health, and
can engage with their patients in addressing health
promotion and disease prevention in creative ways. From
accompanying individual patients through teachable
moments (e.g., the smoker with pneumonia ready to quit)
to influencing civic policy to address homelessness, the
stories entrusted to family physicians in daily practice
are powerful tools for healthy change. These teams
are also key providers in many important public health
areas, including illness and injury prevention; health
promotion; screening and managing chronic diseases;
immunizations; and health surveillance. PMH practices
prioritize delivering evidence-based care for illness and
injury prevention and health promotion, reinforcing
them at each patient visit and other counselling
opportunities. PMHs and local or regional public health
units should cultivate and maintain strong links with one
another. Health care professionals who are part of PMH
teams may take on advisory, educational, supportive, or
active roles in public health initiatives, in many different
occupational, educational, or recreational settings
throughout the community. An effective public health
system should be inextricably linked to communitybased
family physicians and PMHs, recognizing and
supporting them as essential to the achievement of the
broader population and public health goals.
While PMHs focus primarily on the care of individuals
and their families, it is important for team members to
understand and address the health challenges facing
their practice populations and the larger community.
These broader challenges represent upstream factors
(SDoH) that have greater impact on the health of patients
than do the efforts of individual physicians. However,
the relationships embedded in individual and collective
practices can be central to engaging patients and
citizens in building more just and healthier communities
and societies. For example, with the help of HIT, details
about the needs of populations can be more easily
accessed through extraction from practice EMRs, or
participation in programs such as the Canadian Primary
Care Sentinel Surveillance Network (CPCSSN).73 The
CPCSSN networks collect health information from
EMRs of participating primary care providers, extract
anonymous data, and share information on chronic
conditions with governments, health care providers,
and researchers to help inform meaningful systems
and practice change. Programs like the CPCSSN allow
practices to better understand the needs of their
communities and implement specific health promotion
and prevention programs that can contribute to the
population’s overall well-being. Initiatives like this also
ensure the avoidance of data duplication, and recognise
that practices do not need (or have the resources) to
collect data on their own. However, these data are just
a part of caring—the heart of generalism is keeping the
whole in mind while attending to its parts, whether it is
at the level of the whole patient, the whole family, or the
To meet the needs of their diverse panel of patients, family
physicians and other team members in the PMH work to
provide anti-oppressive and culturally-safe care, seeking
to mitigate experiences of discrimination faced by many
patients based on their SDoH. This requires understanding
how historical and current injustices have impacted the
well-being of certain populations, and working to ensure a
safe and welcoming practice environment by focusing on
the principles of caring and compassion.
Sociodemographic data benefits
The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed
about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated
into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data
will also be used for planning and evaluating the FHT’s programs.74
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Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership
Primary care practice teams
Many allied health professional organizations have prioritized the importance of working together in a team to
provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the
CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of
Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes
implementation strategies for creating a primary practice team, and general descriptions of roles found in a
20 A NEW VISION FOR CANADA Family Practice—
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A broad range of services is offered by an interprofessional team. The patient does not always see
their family physician but interactions with all team members are communicated efficiently within a
PMH. The team might not be co-located but the patient is always seen by a professional with relevant
skills who can connect with a physician (ideally the patient’s own personal physician) as necessary.
6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel
of registered patients.
6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or
network, collaborating with the patient’s personal family physician to provide timely access to a broad range
of primary care and consulting services.
6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged
and supported as part of each PMH.
6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team
members may be co-located or may function as part of virtual networks.
6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the
roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers,
physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed.
6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing
ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal
medical home team.
6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles,
professional scopes of practice, and personally acquired competencies. Their roles providing both episodic
and ongoing care support and complement—but do not replace—those of the family physician.
Team-based care is a core function of the PMH. Building
a team with a diverse mix of professional backgrounds
creates an opportunity to redefine what is considered
optimal, based on the needs of the practice and the
community it serves. A high-performing team is essential
to delivering more comprehensive, coordinated, and
effective care centred on the patient’s needs. While
different circumstances call for aspects of patient care
to be provided by different health professionals, it is
important to ensure that family physician expertise is
available to all team members through consultation.
To practice effectively in an interprofessional health care
team, there must be a clear understanding of each member’s
unique contributions, including educational background,
scopes of practice and knowledge, and areas of excellence
and limitations.76 Practices that draw on the expertise of a
variety of team members are more likely to provide patients
with the care they need and respond to community needs.77
Relationships across all dynamics within a practice,
whether between a patient and family physician or
between a patient and other members of the team,
should be encouraged and supported in the PMH.
Establishing these relationships develops trust and
confidence, and works toward the ultimate goal of
achieving better health outcomes. While it should be
left to each practice to determine who does what (within
the boundaries of professional scopes of practice), the
most responsible provider for the medical care for each
patient in the practice should be the patient’s personal
Family physicians with enhanced skills and family
physicians with focused practices play an important role in
collaborating with the patient’s personal family physician
and team to provide timely access to a range of primary
care and consulting services. They supplement their
core skills and experience with additional expertise in a
particular field, while remaining committed to their core
generalist principles.78 These doctors can draw extensively
on their generalist training and approach to disease
management and patient-centred care, enabling them to
work collaboratively at different levels of care, including
with other specialists, to meet patient needs.79 These
clinicians also serve as a resource for other physicians in
their local health system by enhancing care delivery and
learning and teaching opportunities. The Best Advice
guide: Communities of Practice in the Patient’s Medical
Home80 provides more information about intraprofessional
collaboration between family physicians.
Shared care strategies provide patients with timely access
to consultations with other specialists or family physicians
with enhanced skills at scheduled times in the family
practice office setting. The consultant might assess several
patients per visit, at which time a plan for ongoing care
can be developed and agreed to by the family physician,
consultant, other team members, and the patient.
There is no one-size-fits-all model when determining
what mix of health care professionals is right. Team
composition depends on the professional competencies,
skills, and experiences needed to address the health
needs of the patient population.81 These needs vary,
depending on the communities’ defining characteristics;
Additional members of practice teams
Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice
can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices
can also host other health care professionals, such as those employed with a regional health authority, to provide
care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other
health care professionals often carry the overhead costs associated with these practitioners working on site,
and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1:
Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly
funded and have access to the right infrastructure (physical and governance) to support the initiatives described
in this vision.
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22 A NEW VISION FOR CANADA Family Practice—
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for example, geography, culture, language, demographics,
disease prevalence. Family physicians are encouraged
to identify the gaps in health care provision in the local
practice environment and work with other health care
providers to meet those needs as much as possible. Data
from EMRs—as well as input from patients, community
members, and stakeholders—should inform team
planning. Factors to consider include:
Identified community health care needs
Hours available for patient access
Hours available for each physician to work
Roles and number of non-physician providers
Overlapping or variations of similar competencies can
result in ambiguous expectations of what a defined role is
within a practice. When teams are planned and developed,
roles should be clearly outlined. This is best done at the
local practice level relative to community needs and
resources. This approach considers changes over the
course of a health care professional’s career, including
skills development, achievement of certifications, and
professional interests.82 It is important to include time
for team members to become comfortable in their role,
at the outset of team-based care and with any changes
to the team. It is also important to recognize that
these arrangements are flexible and subject to change,
provided the team engages in discussion and reaches
consensus on needed adjustments.
Team members might be in the same office or in the same
building, but this is not necessary. For smaller and more
remote practices, or larger urban centres where proximate
physical space may be a barrier, some connections may
be arranged with peers in other sites. Applying HIT
judiciously allows for virtual referrals and consultations.
Virtual links between PMH practices and other specialists,
hospitals, diagnostic services, etc., can be enhanced with
more formal agreements and commitments to provide
timely access to care and services.
By providing patients with a comprehensive array of
services that best meet their needs, team-based care
can lead to better access, higher patient and provider
satisfaction, and greater resource efficiency.61,77,83
Although there are presently many systems in place that
support the creation of health care teams, practices can
also create a successful team on their own. To ensure
team success, providers must have a clear understanding
of the different role responsibilities and ensure that
there are tools available to engage open dialogue and
communication. Teams within the PMH are supported by
a model that is flexible and adaptable to each situation.
The skills that family physicians acquire during their
training (as described in the CanMEDS-FM framework)
make them well suited to provide leadership within
interprofessional teams. As an important part of a PMH,
teams are central to the concept of patient-centred care
that is comprehensive, timely, and continuous.
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Pillar 7: Continuity of Care
Continuity of care is defined by consistency over time
related to where, how, and by whom each person’s medical
care needs are addressed throughout the course of their
life.84 With strong links to comprehensive team-based
care (see Pillar 6: Comprehensive Team-Based Care
with Family Physician Leadership), continuity of care
is essential to any practice trying to deliver care truly
centred on the needs of the patient. Continuity of care
is rooted in a long-term patient-physician partnership
in which the physician knows the patient’s history from
experience and can integrate new information and
decisions from a whole-person perspective efficiently
without extensive investigation or record review.84 From
the patient’s perspective, this includes understanding
each person’s life journey and the context this brings
to current health status, and the trust they have in their
provider that is built over time.
Past studies show that when the same physician attends
to a person over time, for both minor and more serious
health problems, the patient-physician relationship is
strengthened and understanding grows—an essential
element of effective primary health care.85 The personal
physician offers their medical knowledge and expertise
for a more complete understanding of the patient as
a person, including the patient’s medical history and
their broader social context, such as personal, family,
social, and work histories (see Pillar 5: Community
Adaptiveness and Social Accountability). In this model,
patients, their families and/or personal caregivers, and
all health care providers in the PMH team are partners in
care, working together to achieve the patient’s goals and
engaging in shared decision making. Understanding the
patient’s needs, hopes, and fears, and their patterns of
response to illness, medications, and other treatments,
deepens the physician’s ability to respond to larger
trends, not just the medical issue presented at any given
appointment. Continuity of care can ideally support the
health and well-being of patients actively and in their daily
lives without focusing only on care when they are ill. The
strong physician-patient relationship developed over time
allows them to maintain good health and prevent illness
and injury, as the physician uses their deep knowledge
of their patient to work with teams of qualified health
professionals to best support the patient’s well-being.
Family physicians in the PMH, acting as the most
responsible provider, can provide continuous care
over the patient’s lifespan and develop strong
relationships with patients. Research demonstrates
that one of the most significant contributors to better
population health is continuity of care.86,87 It found
that those who see the same primary care physician
continuously over time have better health outcomes,
reduced emergency department use, and reductions
in hospitalizations versus those who receive care
from many different physicians. A Canadian study
found that after controlling for demographics and
health status, continuity of care was a predictor
of decreased hospitalization for ambulatory caresensitive
conditions (such as such as COPD, asthma,
diabetes, and heart failure) and decreased emergency
department visits for a wide range of family practicesensitive
conditions.85 Overall “the more physicians
patients see, the greater the likelihood of adverse
effects; seeking care from multiple physicians in
Patients live healthier, fuller lives when they receive care from a responsible provider who journeys
with them and knows how their health changes over time.
7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby
ensuring continuous care across the patient’s lifespan.
7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the
family practice office, hospitals, long-term care and other community-based institutions, and the patient’s
7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical
services their patients receive throughout the medical community.
the presence of high burdens of morbidity will be
associated with a greater likelihood of adverse side
effects.”86 It has been reported that a regular and
consistent source of care is associated with better
access to preventive care services, regardless of the
patient’s financial status.
Continuity of care also requires continuity in medical
settings, information, and relationships. Having most
medical services provided or coordinated in the same
place by one’s personal family physician and team
has been shown to result in better health outcomes.88
As described in Pillar 3: Connected Care, when care
must be provided in different settings or by different
health professionals (i.e., the medical neighbourhood),
continuity can still be preserved if the PMH plays a
coordination role and communicates effectively with
other providers. The PMH liaises with external care
providers to coordinate all aspects of care provided
to patients based on their needs. This includes but is
not limited to submitting and following up on referrals
to specialized services, coordinating home care, and
working with patients before and after discharge from
hospitals or other critical care centres.
In addition to this coordination role, the PMH acts as
a hub by sharing, collecting, storing, and acting as a
steward for all relevant patient information. This ensures
that the family physician, as the most responsible provider,
has a complete overview of the patient’s history. A record
of care provided for each patient should be available in
each medical record (preferably through an EMR) and
available to all appropriate care providers (see Pillar 2:
Appropriate Infrastructure for more information about
EMRs). Knowing that medical information from all sources
(i.e., providers inside and outside the PMH) is consolidated
in one location (physical or virtual) increases the comfort
and trust of patients regarding their care.
Continuity for patient health
Research demonstrates that continuity of care is a key contributor to overall population health. Patients
with a regular family physician experience better health outcomes and fewer hospitalizations as compared
to those without.69
24 A NEW VISION FOR CANADA Family Practice—
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.
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Family practices respond to the unique needs of patients and their families within the context of
8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’
feelings, preferences, and expectations.
8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making
8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as
agreed upon with their care team.
8.4 Self-managed care is encouraged and supported as part of the care plans for each patient.
8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g.,
telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH.
8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys)
are part of ongoing planning and evaluation.
As part of their commitment to patient-centred care, PMH
practices facilitate and support patient self-management.
Self-management interventions such as support for
decision making, self-monitoring, and psychological and
social support, have been demonstrated to improve
health outcomes.95 PMH team members should always
consider recommendations for care from the patient’s
perspective. They should work collaboratively with
patients and their caregivers to develop realistic action
plans and teach problem-solving and coping. This is
particularly important for those with chronic conditions,
who must work in partnership with their physician
and health care team to manage their condition over
time. (Refer to the Best Advice guide: Chronic Care
Management in a Patient’s Medical Home96 for more
information). The goal of self-managed care should be
to build the patient’s and caregiver’s confidence in their
ability to deal effectively with illnesses, improve health
outcomes, and foster overall well-being.
To facilitate patient- and family-partnered care, a range
of user-friendly options for accessing information
and care beyond the traditional office visit should
be available to patients when appropriate. These
include email, telehealth, virtual care, mobile health
units, e-consults, home visits, same-day scheduling,
group visits, self-care strategies, patient education,
and treatment sessions offered in community settings.
Providing a range of options allows patients to access
the type of care they prefer based on individual needs.
Patients also need to be informed about how they can
access information and resources available to them; for
example, resources such as Prevention in Hand (PiH).97
Allowing patients to access to their medical records
can improve patient-provider communication and
increase patient satisfaction.98,99 The specific information
accessible to patients should be discussed and agreed
upon by the patient and their care team. Patient
education about accessing and interpreting the available
information is necessary. Facilitating this type of access
requires each PMH to have an EMR system that allows
external users to access information securely (see Pillar
2: Appropriate Infrastructure).
Patient surveys and opportunities for patients to
participate in planning and evaluating the effectiveness
of the practice’s services should be encouraged; practices
must be willing respond and adapt to patient feedback.
To strengthen a patient-centred approach, practices may
consider developing patients’ advisory councils or other
formalized feedback mechanisms (e.g., using patient surveys)
as part of their CQI processes (see Pillar 9: Measurement,
Continuous Quality Improvement, and Research).
The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can
improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an
environment of learning and seeks to encourage health literacy among its patients through its various programs.
The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to
patients to remove financial barriers to access.
26 A NEW VISION FOR CANADA Family Practice—
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A NEW VISION FOR CANADA Family Practice—
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Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to
Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional
28 A NEW VISION FOR CANADA Family Practice—
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Continuous quality improvement
CQI is an important value among health organizations such as the CFHI.100
Pillar 9: Measurement, Continuous Quality
Improvement, and Research
CQI is an essential characteristic of the PMH vision.
It encourages health care teams to make practical
improvements to their practice, while monitoring the
effectiveness of their services, the health outcomes
and safety of their patients, and the satisfaction of
both patients and the health professionals on the team.
Every PMH is committed to establishing a CQI program
that will improve patient safety, and enhance efficiency
and quality of the services provided to patients. As
part of CQI activities, a structured approach is used
to evaluate current practice processes and improve
systems and to achieve desired outcomes.
To engage in CQI, the PMH team must identify the
desired outcomes and determine appropriate evaluation
strategies. Once the process and the desired outcome
are defined with patients, the CQI activity will track
performance through data collection and comparison
with the baseline. Performance measures can be
captured through structured observation, patient and
staff surveys (see Pillar 8: Patient- and Family-
Partnered Care), the PMH self-assessment tool,
and the practice’s EMR (see Pillar 1: Administration
and Funding and Pillar 3: Connected Care). The
indicators selected should be appropriate to each
practice and community setting, be meaningful to
the patients and community, and the CQI process
could be introduced as a practice’s self-monitoring
improvement program or as an assessment carried
out by an external group.
In some jurisdictions, funding is tied to achieving
performance targets, including those that provide
evidence for the delivery of more cost-effective care
and better health outcomes.101 Some provinces in
Canada have begun to link financial incentives to clinical
outcomes and targets that have been achieved (“pay
for performance” models).102 Although there may be
some benefits derived by this approach, there can also
be risks if funding incentives and resource supports
become overly focused on patients with certain medical
problems or on those who have greater potential to reach
prescribed targets, while at the same time care is being
delayed or denied for others.101,103 Future development
A NEW VISION FOR CANADA Family Practice—
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Family practices strive for progress through performance measurement and CQI. Patient safety is always
a focus, and new ideas are brought to the fore through patient engagement in QI and research activities.
9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and
the services they provide for patient and provider satisfaction.
9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH.
9.3 All members of the health professional team (both clinical and support teams), as well as trainees and
patients, will participate in the CQI activity carried out in each PMH.
9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate
in research carried out in their practice settings.
9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the
effectiveness of care and services.
A NEW VISION FOR CANADA Family Practice—
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of financial incentive models should consider these
unintended consequences that might impair the ability
of practices to provide good quality patient care to their
The objectives that define a PMH could be used to develop
the indicators for CQI initiatives in family practices
across Canada. These criteria could be augmented
by indicators recommended by organizations such as
Accreditation Canada, Health Quality Ontario, Health
Standards Organization, and the Patient-Centered
Medical Home model in the United States. The CFPC is
committed to collaborating with these groups to further
develop the CQI process for PMHs and family practices.
Consult the CFPC’s Practice Improvement Initiative
(Pii)104 for a list of available resources.
CQI is a team activity and should involve all members
of the PMH team as well as patients and trainees. This
will ensure buy-in from the team, allow for patient
engagement and participation, and provide trainees with
valuable learning opportunities.105 PMHs are committed
to using the results of CQI initiatives to make tangible
changes in their practice to improve operations, services,
Time and effort invested into participation in CQI
activities should be recognized as valuable and not be
disincentivized through existing remuneration models.
Dedicated time and capacity to perform these activities
should be built into the practice operational principles.
On a larger scale, PMHs function as ideal sites for
community-based research focused on patient health
outcomes and the effectiveness of care and services.
The PMH team should be encouraged and supported
to participate in research activities. They should also
advocate for medical students, residents, and trainees
to take part in these projects. In Canada, the Canadian
Primary Healthcare Research Network (CPHRN) and
the commitment of the Canadian Institutes for Health
Research’s (CIHR’s) Strategy for Patient-Oriented
Research (SPOR) are vitally important.106 The focus on
supporting patient-oriented research carried out in
community primary care settings is consistent with the
priorities of the PMH.
Competitions for research grants such as those
announced by SPOR should be strongly encouraged
and supported. PMHs are ideal laboratories for
studies that embrace the principles of comparative
effectiveness research (CER) and the priorities
defined by the CPHRN and CIHR’s SPOR project.
They provide excellent settings for multi-site research
initiatives, including projects like those currently
undertaken by the CPCSSN—a nationwide network of
family physicians conducting surveillance of various
30 A NEW VISION FOR CANADA Family Practice—
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Pillar 10: Training, Education, and
Continuing Professional Development
PMH practices serve as training sites for medical
students, family medicine residents, and those training
to become nurses and other health care professionals.107
They create space for modelling and teaching practices
focused on the essential roles of family physicians and
interprofessional teams as part of the continuum of a
health care system. One of the goals of family medicine
residency training is for residents to learn to function
as a member of an interdisciplinary team, caring for
patients in a variety of settings including family practice
offices, hospitals, long-term care and other communitybased
institutions, and patients’ residences.70,108
A PMH also models making research and QI initiatives
a standard feature of a family practice. Professional
development and opportunities to participate in these
activities should be available and supported within PMH
practices through resources, guidance, and specifically
Family medicine training is increasingly focused on
achieving and maintaining competencies defined by the
CFPC’s Triple C Family Medicine Curriculum.109 Triple C
includes five domains of care: care of patients across the
life cycle; care across clinical settings (urban and rural);
a defined spectrum of clinical responsibilities; care of
marginalized/disadvantaged patients and populations;
and a defined list of core procedures. Triple C also
incorporates the Four Principles of Family Medicine and
the CanMEDS-FM Roles.
PMHs allow family medicine students and residents to
achieve the competencies of the Triple C curriculum and
to learn how to incorporate the Four Principles of Family
Medicine, the Family Medicine Professional Profile, and
the CanMEDS-FM roles into their professional lives.
Learners gain experience with patient-partnered care,
teams/networks, EMRs, timely access to appointments,
comprehensive continuing care, management of
undifferentiated and complex problems, coordination of
care, practice-based research, and CQI—essential elements
of family practice in Canada. Furthermore, PMH practices
serve as optimal sites for trainees in other medical specialties
and health professions to gain valuable experience working
in interprofessional teams and providing high quality,
patient-centred care. Medical schools and residency
programs should encourage learners to conduct some of
their training within PMH practices.
Emphasis on training and education ensures that the knowledge and expertise of family physicians can
be shared with the broader health care community, and also over time by creating learning organizations
where both students and fully practising family physicians can stay at the forefront of best practice.
10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations
for the experiential training of their students and residents.
10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks,
EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated
and complex problems, coordination of care, practice-based research, and CQI.
10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to
achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the
Four Principles of Family Medicine, and the CanMEDS-FM Roles.
10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development
(CPD) to meet the needs of their patients and their communities both individually and as a team.
10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community.
Practising family physicians must engage in CPD to keep
current on medical and health care developments and
to ensure their expertise reflects the changing needs of
their patients, communities, and learners.
Mainpro+® (Maintenance of Proficiency) is the CFPC’s
program designed to support and promote family
physicians’ CPD across all CanMEDS-FM Roles and
CPD refers to physicians’ professional obligation to
engage in learning activities that address their own
identified needs and the needs of their patients;
enhance knowledge, skills, and competencies across all
dimensions of professional practice; and continuously
improve their performance and health care outcomes
within their scope of practice.110 Three foundational
principles for CPD in Canada have been recently
Socially responsive to the needs of patients and
Informed by scientific evidence and practicebased
Designed to achieve improvement in physician
practice and patient outcomes
CPD is inclusive of learning across all CanMEDS-FM
Roles and competencies, including clinical expertise,
teaching and education, research and scholarship, and
in practice-based QI.
PMH practices support their physicians, and all other staff
members, to engage in CPD activities throughout their
careers by creating a learning culture in the organization.
This includes providing protected time for learning and
team-based learning, and access to practice data both
to discern patient/community need and practice gaps
to inform CPD choices and to evaluate the impact of
learning on patient care. This learning culture and the
will to be constantly improving quality and access to
care is essential to ensuring that the PMH continues to
support high performing care teams.
To ensure that all PMH team members have the capacity
to take on their required roles, leadership development
programs should be offered. Enabling physicians to
engage in this necessary professional development
requires sufficient funding by governments to cover
costs of training and financial support to ensure lost
income and practice capacity do not prevent this.
Physicians in the PMH share their knowledge with
colleagues in the broader health care community and
with other health care professionals in the team by
participating in education, training, and QI activities
in collaboration with the pentagram partners.† This
is particularly relevant for family physicians who are
focused on a particular area of practice (possibly
holding a Certificate of Added Competence) and are
able to share their extended expertise with others. This
can happen either informally or through more official
channels. For example, physicians may participate in
activities organized by the CFPC or provincial Chapters
(e.g., Family Medicine Forum, provincial family medicine
annual scientific assemblies), or lend their expertise to
interprofessional working groups addressing specific
topics in health care. Family physicians should be
encouraged to engage in these types of events to share
their knowledge and skills for the betterment of the
overall health system.
Continuing professional development
CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA,
and CNA emphasize the value and importance of continuing education for health care professionals to improve
† Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education
administrators; university; community; health professionals—physicians and teams
A NEW VISION FOR CANADA Family Practice—
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32 A NEW VISION FOR CANADA Family Practice—
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The revised PMH vision of a high-functioning primary
care system responds to the rapidly evolving health
system and the changing needs of Canadians. The pillars
and attributes described in this document can guide
practices at various stages in the transition to a PMH,
and many characteristics are found in other foundational
documents of family medicine such as the Family
Medicine Professional Profile111 and the Four Principles
of Family Medicine. Supporting resources, such as the
PMH Implementation Kit, are available to help those
new to the transition overcome barriers to change.
Although the core components of the PMH remain the
same for all practices, each practice will implement the
recommendations according to their unique needs.
The PMH is focused on enhancing patient-centredness
in the health care system through collaboration, access,
continuity, and social accountability. It is intended to
build on the long-standing historical contribution of
family physicians and primary care to the health and wellbeing
of Canadians, as well as on the emerging models
of family practice and primary care that have been
introduced across the country. Importantly, this vision
provides goals and recommendations that can serve as
indicators. It enables patients, family physicians, other
care health professionals, researchers, health planners,
and policy-makers evaluate the effectiveness of any and
all models of family practice throughout Canada.
Those family practices that meet the goals and
recommendations described in this vision will have
become PMHs, but the concept is ever evolving. As family
physicians commit to making change in their practices,
the CFPC commits to supporting developments in the
PMH by creating and promoting new resources, which
will be available through the PMH website. The CFPC
will also play an important advocacy role to ensure that
the necessary supports are in place to reach the goals of
a PMH. Every family practice across Canada should be
supported and encouraged by the public, governments,
and other health care stakeholders (the pentagram
partners) to achieve this objective. Doing so will ensure
that every person in Canada is able to access the best
possible primary care for themselves and their loved ones.
A NEW VISION FOR CANADA Family Practice—
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Hockey is one of the most popular sports for Canadian children and youth. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries, particularly concussion. Studies consistently identify bodychecking as the primary mechanism associated with youth hockey injuries, including concussion. Policy to delay bodychecking until bantam league play (when participants are 13 to 14 years of age) will reduce the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from non-elite youth ice hockey. The age at which bodychecking is introduced in competitive hockey leagues must be reconsidered. Both initiatives require policy change in many provinces/territories, and must be re-evaluated prospectively in light of emerging research.
More than 4.5 million Canadians are involved in ice hockey, as coaches, officials, administrators or direct volunteers, and hockey is the most popular winter sport among Canadian children and youth. Hockey Canada reported over 550,000 registered players under the age of 19 in 2008, and participation rates are increasing, especially among girls and young women. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries in youth, particularly concussion. The American Academy of Pediatrics (AAP) classifies hockey as a collision sport because of unintentional and intentional body contact, including bodychecking.
The AAP published a policy statement on youth ice hockey in 2000, recommending that bodychecking not be allowed for children younger than 15 years of age. There is passionate debate about the risk factors for injury in youth hockey and the relative merits of early or later introduction of bodychecking. Because bodychecking is not allowed in girls' or women's hockey in Canada, the present statement pertains to play in boys' and men's hockey leagues. It reviews the scientific literature on bodychecking injuries, outlines positions in the current debate and makes recommendations on when bodychecking should be introduced into the game.
DEFINING BODY CONTACT AND BODYCHECKING
Body contact is an individual defensive tactic designed to legally block or impede the progress of an offensive puck carrier. The defensive player moves to restrict action by the puck carrier anywhere on the ice, by skating, angling and positioning. The defensive player cannot hit the offensive player by travelling in an opposite direction to him or by physically extending toward him in an effort to initiate contact. There must be no action where the puck carrier is pushed, hit or shoved into the boards. In contrast, bodychecking is an individual defensive tactic designed to legally separate the puck carrier from the puck. The defensive player physically extends his body toward the puck carrier while moving in an opposite or parallel direction, a deliberate and forceful move not solely determined by the movement of the puck carrier. Bodychecking is taught based on a four-step skill development program outlined by Hockey Canada, with progression through positioning and angling, stick checking, body contact and bodychecking skills. Instruction in bodychecking includes techniques for receiving bodychecks, adhering to rules, and safe play.
Hockey Canada groups children and adolescents by age into six play levels: initiation (5 to 6 years of age), novice (7 to 8 years), atom (9 to 10 years), peewee (11 to 12 years), bantam (13 to 14 years), and midget (15 to 17 years). Historically, from the early 1980s until the 2002/2003 season, bodychecking was introduced at age 12 years in Canadian boys' ice hockey. In 2003, four of 13 provincial/territorial branches allowed checking for players as young as nine years old. Hockey Canada mandated the introduction of bodychecking in peewee leagues (ages 11 to 12) in 2009. Quebec has delayed bodychecking until bantam (age 14 from 1978 to 2002, then age 13 following an age change mandated nationally).
Despite lack of evidence, proponents of bodychecking argue that it is a fundamental skill which, learned early, may prevent future injuries. However, the evidence supports that bodychecking is the most common mechanism of injury. The Canadian Academy of Sports Medicine recommends that bodychecking be introduced only in boys' competitive hockey, and no earlier than the bantam (ages 13 to14) or midget (ages 15 to 17) level. The AAP recommends a ban on bodychecking for male players younger than 15 years of age. The present statement marks the first CPS position on this issue.
BODYCHECKING AND INJURY
Hockey is recognized as a high-risk sport. The speed of play, body contact and bodychecking all contribute to injury risk. The injury rate is also high, with Canadian data suggesting that hockey injuries account for 8% to 11% of all adolescent sport-related injuries. Unfortunately, serious injuries such as concussion, other brain injuries and spinal cord trauma are not uncommon in hockey. The incidence of traumatic brain injury appears to be rising. Ice hockey-related fatality rates are double those reported in American football, and catastrophic spinal cord and brain injury rates are almost four times higher for high school hockey players than for high school and college football players. Bodychecking is the predominant mechanism of injury among youth hockey players at all levels of competition where it is permitted, accounting for 45% to 86% of injuries.- Several published studies, including two recent systematic reviews, reported on risk factors for injury (including bodychecking) in youth hockey. Emery and colleagues conducted a systematic review of 24 studies and a meta-analysis including only studies which examined policy allowing bodychecking as a risk factor for injury. Policy allowing bodychecking was found to be a risk factor for all hockey injuries, with a summary incidence rate ratio (IRR) of 2.45 (95% CI 1.7 to 3.6). Furthermore, policy allowing bodychecking was found to be a risk factor for concussion, with a summary OR of 1.71 (95% CI 1.2 to 2.44). These data confirm that bodychecking increases the risk of all injuries and the risk of concussion specifically. Nine of ten studies examining policy allowing bodychecking provided evidence to support a greater risk in bodychecking leagues. The second systematic review found the RR of injury associated with policy allowing bodychecking ranged from 0.6 to 39.8; all but one of these studies found an increased risk of injuries associated with bodychecking.
Since the publication of these systematic reviews there have been five additional studies. A Canadian prospective cohort study compared injury rates between peewee ice hockey players in a league where bodychecking is permitted at age 11 years (Alberta) versus players in a league where bodychecking is not permitted until age 13 (Quebec). During the 2007/2008 season, a validated injury surveillance system was used to capture all injuries requiring medical attention and/or time loss from hockey (ie, time between injury and return to play) in 2154 players. There was a threefold increased risk of all game-related injuries (IRR =3.26 [95% CI; 2.31 to 4.60]) and of injury resulting in >7 days time lost from sport (IRR=3.30 [95% CI; 1.77 to 6.17]) in 11- to 12- year-old peewee players from Alberta when compared with Quebec. There was also an almost fourfold increased risk of game-related concussion (IRR=3.88 [95% CI; 1.91 to 7.89]) in Alberta peewee players. Further evidence was reported in a five-year cohort study (2002 to 2007) including all age groups, which demonstrated that injury risk increases 3.75 times (IRR=3.75 [95% CI; 1.51 to 9.74]) in leagues that allow bodychecking compared with those that do not.
A second prospective cohort study by Emery et al examined whether the introduction of bodychecking at 11 years of age (Alberta) or 13 years of age (Quebec) affected injury rates in later years (at 13 to 14 years of age). During the 2008/09 season, the same injury surveillance system cited above was used to study 1971 bantam players (13- to 14-year-olds). There was no reduction in game-related injury risk (all injuries) for this age group (IRR=0.85 [95% CI 0.63 to 1.16]), of concussion specifically (IRR=0.84 [95% CI 0.48 to 1.48]), or of concussions resulting in >10 days time lost from sport (IRR=0.6 [95% CI 0.26 to 1.41]) in the Alberta league, compared with Quebec. In fact, the concussion rate found in Alberta peewee players was higher than in bantam players in either province. Injuries to bantam players resulting in >7 days time lost from sport were reduced by 33% (IRR=0.67 [95% CI 0.46 to 0.99]) in the Alberta league, where players had had two years of bodychecking experience. However, these findings must be interpreted in light of the three- to fourfold greater injury and concussion risk among peewee players in Alberta, along with a possibly higher 'survival effect' among peewee players moving on to bantam in Quebec when compared with Alberta, where bodychecking is allowed in peewee league play.
Recent retrospective studies have examined the influence of policy change based on the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) surveillance data. Injury rates among boys presenting to emergency departments in the Kingston, Ontario area both before and after the 2002 rule change to allow bodychecking in younger players, were reported. There was no change between bodychecking injury rates in 1997 to 2002 (with bodychecking introduced at 11 years of age) and 2003 to 2007 (when bodychecking was introduced at nine years of age). Overall rates of injury actually declined over the later period. However, this retrospective study may also be biased by stronger rule enforcement, better coaching certification and temporal declines in emergency department use for this type of injury over that period. In contrast, retrospective research of CHIRPP data from 1994 to 2004 in five Ontario hospitals examined injury risk following a rule change in 1998 that allowed bodychecking in nine- and 10-year-old hockey players. A 2.2 times greater risk of injury in atom players (9 and 10 years of age) after the rule change was reported (OR=2.2 [95% CI 1.7 to 2.84]). Another retrospective study using CHIRPP data (from 1995 to 2002) compared hockey injuries in children 10 to 13 years of age playing in Ontario, where bodychecking was allowed, with data from Quebec, where bodychecking was not allowed. There was a 2.6 times greater risk of bodycheck-related injuries reported for this age group when bodychecking was allowed (OR=2.65 [95% CI 2.21 to 3.18]).
OTHER RISK FACTORS
After policy that permits bodychecking, the most commonly investigated risk factors for injury in the scientific literature are: age, session-type (ie, a practice versus a game), level of play, player position, physical size, and a previous history of injury and/or concussion. Most studies examining age found that injury risk increased with age; others suggest no elevated injury risk in older age groups.- Relative age has been examined to "describe the potential advantages (or disadvantages) that result from age differences between peers within one age group". One study examining relative age among hockey players found no evidence that younger (or older) players within a grouping were at elevated injury risk. Additional research supports this finding at the peewee level, where no increased risk was found in first-year players. In bantam leagues, however, there was a 40% greater risk of injury in first-year players when compared with players in their second year.
Based on session-type, injury risk is reported to be consistently higher in games than in practices, with RR estimates ranging from 2.45 to 6.32. One study also indicated that injury rates were higher in regular season play than during preseason, postseason or tournament games.
In general, studies examining level of play have found that injury risks rise with increasing skill levels across all age groups. However, one study reported that only peewee players in the highest skill division were at the greatest risk of injury, with no significant increase by skill level in other age groups. Larger cohort studies confirmed a consistently greater risk of injury among peewee players who were more highly skilled, but this trend was not observed in the bantam age group.
When examining player position, some researchers found that forwards were at higher risk of injury than defencemen or goalies,  while others reported the relative risk of injury was 2.18 times higher for defencemen than forwards. In all three studies, goalies were shown to be at much lower risk than other players. Additional research shows a consistent protective effect for goalies at both the peewee and bantam levels.
Research on player size has shown conflicting results, with some studies citing increased risk for smaller players in some age groups. Prospective Canadian data show a significantly greater risk of injury in peewee players in the lowest 25th percentile by weight,  though this finding was not reflected in the bantam cohort. However, additional research has found lighter bantam players to be at greater risk, while other studies report a significant weight difference, at all levels, between players who sustained a bodychecking-related injury and those who did not. Other research examining body weight as a risk factor for shoulder injuries found that heavier players were at greater risk for these injuries. One study looked at height as a possible risk factor for injury and found no evidence of effect among bantam players.
By contrast, a history of previous injury or concussion is consistently reported as a significant risk factor for reinjury and further concussion, respectively. One recent Canadian peewee cohort study showed that the risk of injury doubled for players who reported being injured within the past year (IRR=2.07 [95% CI 1.49 to 2.86]), while the risk of concussion tripled for players reporting any previous concussion (2.76 [95% CI 1.1 to 6.91]). The bantam cohort also showed greater risk of reinjury and concussion in players reporting previous injury within the past year (IRR=1.39 [95% CI 1.13 to 1.71]) or any previous concussion (IRR=1.87 [95% CI 1.19 to 2.94]), respectively.
INJURY PREVENTION AND RISK REDUCTION
Injury prevention and risk reduction programs have been implemented but have not been evaluated rigorously. The STOP (Safety Towards Other Players) program (www.safetytowardsotherplayers.com) is supported by the Ontario Minor Hockey Association (www.omha.net), and includes an education component and the "STOP patch", which is sewn on the back of players' uniforms to remind opponents not to hit from behind. A study evaluating another injury prevention program, "Fair Play", which awards points for sportsmanlike play (based on penalty minutes), suggests an approximate 60% reduction in the risk of injury (OR=0.41 [95% CI 0.11 to 1.47]) where the program is in effect, but the results were not statistically significant.
Players, parents, coaches, officials and trainers must be mindful of the potential risks of playing hockey. Hockey Canada has player development, coaching, education and safety promotion programs and resources for coaches, officials, players and parents at www.hockeycanada.ca. Concussion awareness is vital. Athletes and all those involved in their care need to know about the risks, symptoms/signs and how to manage concussive injuries. The CPS statement on concussion evaluation and management is essential reading , with additional information available from the Canadian Academy of Sport and Exercise Medicine (www.casm-acms.org), ThinkFirst Canada (www.thinkfirst.ca) and the US Centers of Disease Control and Prevention (www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm).
Studies consistently identify bodychecking as the primary mechanism of hockey-related injuries, including concussion. It is expected that delaying the introduction of bodychecking until the bantam level and restricting bodychecking to elite leagues for older age groups will reduce the risks of injury and concussion substantially. Delaying bodychecking until bantam will have a clear benefit in reducing the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from recreational youth ice hockey and the age at which it is introduced in competitive hockey leagues should be reconsidered. Both initiatives require policy change in many provinces/territories in Canada, and policy changes will need to be evaluated on a regular basis in light of emerging research.
The Canadian Paediatric Society recommends the following:
* Eliminating bodychecking from all levels of organized recreational/non-elite competitive male ice hockey. (Grade II-2A evidence) *
* Delaying the introduction of bodychecking in elite male competitive leagues until players are 13 to 14 years of age (bantam level) or older. (Grade III-C evidence)*
* Implementing Hockey Canada's four-stage skill development program for bodychecking (body positioning, angling, stick checking and body contact) for all leagues.
* Educating coaches and trainers, schools, and policy-makers in sport about the signs and symptoms of common hockey injuries, especially concussion.
* Improving injury surveillance to better identify the risk factors for, and mechanisms of, hockey injuries.
* Policies to reduce injury and promote fair play in hockey, for all age groups and league levels.
Clinicians who see young hockey players in their practice should offer the following advice:
* Girls and young women should continue participating in non-bodychecking leagues.
* Boys should play in recreational/non-elite hockey leagues that do not allow bodychecking.
* Elite male players should play in hockey leagues that introduce bodychecking later, when players are 13 to 14 years of age (bantam level) or older.
* All players should adhere to fair play and a non-violent sport culture.
* Parents and caregivers should learn injury prevention and risk reduction strategies, including concussion prevention, recognition and management.
*The levels of evidence and strength of recommendations are based on the Canadian Task Force on Preventive Health Care (See Table 1). 
TABLE 1: [SEE PDF]
Levels of evidence and strength of recommendations
Level of evidence
Evidence obtained from at least one properly randomized controlled trial.
Evidence obtained from well-designed controlled trial without randomization.
Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group.
Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category.
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.
There is good evidence to recommend the clinical preventive action.
There is fair evidence to recommend the clinical preventive action.
The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making.
There is fair evidence to recommend against the clinical preventive action.
There is good evidence to recommend against the clinical preventive action.
There is insufficient evidence to make a recommendation; however, other factors may influence decision-making.
This statement was reviewed by the Community Paediatrics and Injury Prevention Committees of the Canadian Paediatric Society. Thanks to Drs. Claire MA LeBlanc, Stan Lipnowski, Peter Nieman, Christina G Templeton and Thomas J Warshawski for their input as past members of the CPS Healthy Active Living and Sports Medicine Committee.
HEALTHY ACTIVE LIVING AND SPORTS MEDICINE COMMITTEE
Members: Catherine Birken MD; Tracey L Bridger MD (Chair); Mark E Feldman MD (Board Representative); Kristin M Houghton MD; Michelle Jackman MD; John F Philpott MD
Liaison: Laura K Purcell MD, CPS Paediatric Sports and Exercise Medicine Section
Principal authors: Kristin M Houghton MD; Carolyn A Emery PT PhD
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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.