Patient Medical Homes (PMH) and Primary Care Networks (PCN)

What is a patient medical home?

The patient medical home is a family practice where doctors work with teams of health professionals and in networks to bring services together around patients, and where patients experience timely access to continuous, coordinated care. 

It positions family practices at the centre of an integrated system of care, and is a proven way for providers to work together more effectively to ensure patients get access to coordinated, quality care. A patient medical home has 12 key attributes. Read more.

Why is it important to build patient medical homes?

Patients can get better access to timely and coordinated primary care across health care practitioners and locations, starting at the family practice.

Doctors have stronger connections to team-based support and community-based care for patients, especially those with complex needs like the frail elderly, and patients with mental health needs.

What is a primary care network?

It is a group of linked patient medical homes in a defined geography linked with primary care services delivered by a health authority and other community-based organizations and services.

How will patient medical homes help patients?

Patient medical homes bring a range of services together to wrap around the patient. Patients will have better access to timely and coordinated care across health care practitioners and locations, starting at the family practice.

How will patient medical homes help doctors?

The patient medical home model can help to ease pressures in a practice and on doctors to deliver quality patient care. With the support of teams and networks of other health professionals – such as nurses, social workers and mental health professionals - and with stronger connections to the community:

  • Doctors know their patients can get the care they need, in the right place at the right time.
  • Doctors can more easily access care in the community to support patients with complex health needs. A doctor does not have to shoulder the responsibility alone.
  • Doctors can maximize their own time and role, achieve better work-life balance and look out for their own wellness.
  • Doctors can work in a more healthy, supportive work environment.

Aren't doctors already doing this work?

Some are, some aren’t. Family practices are at different places.  Some may need to make changes, while others won’t. Doctors in rural and remote geographic areas in BC may already be working in a variety of similar models.

What will stay the same?

The PMH model builds on primary care changes that physicians have been leading for the last decade, most recently through initiatives like the A GP for Me and residential care initiatives and the GPSC fee incentives. It is the next step in the evolution of primary care.

  • Some attributes of the patient medical home are what doctors are already doing: patient-centered care, commitment (attachment), coordination, contact (access), continuity and comprehensiveness of care.
  • The GPSC support for full service family practice with emphasis on attachment and longitudinal patient care relationships will continue.
  • Some communities and practices – particularly in rural areas – already work this way to a great extent.

What is new?

Key areas of change for some practices and communities include:

  • Doctors will have opportunities to work with more teams of health professionals.
  • Due to a major realignment of the health authorities’ primary and community care services, it will be easier for doctors to access specialized services for patients in the community.
  • Doctors will be supported by more physician networks.
  • Doctors will be supported to use data in more robust ways to improve the quality of care.

What do doctors think of this work?

Physicians said through the Doctors of BC Visioning consultation that they are open to new and different ways of practicing so they can provide the best care possible for their patients, while achieving a healthy work-life balance. We also know that newer doctors want to practice in more flexible, team-oriented work environments.

How does the practice pay for these changes?

  • Opportunities underway (with more information to come) include:
  • Exploration of financial options both within and outside the fee-for-service structure, and through practice-level incentive fees.
  • $250,000 for each division from GPSC to resource the patient medical home development and change management work in their communities.
  • Targeted tools, resources and teams for divisions and practices from GPSC programs like the Practice Support Program and Doctors Technology Office.
  • A provincial government commitment $90 million over the next three years to expand team-based primary and community care across BC, including to add nurses, nurse practitioners to family practices and connect other health professionals to doctors, and to establish inter-professional, community teams for vulnerable populations.

Why is it important to assess the practice's panel when establishing patient medical homes?

Understanding a practice’s patient panel and population can improve proactive planned care and identify the needs of a practice. It is a foundational step to achieving the attributes of the Patient Medical Home. For support, please email the Practice Support Program.