Please explain in simple terms – what is a patient medical home? a primary care home?

The patient medical home is a family physician’s enhanced practice, defined as the place patients feel most comfortable to discuss their personal and health concerns. The Most Responsible Provider – usually the family doctor – works collaboratively with a team of health professionals, either within or linked with the practice, to deliver longitudinal, comprehensive and coordinated care of patients. Click here for a full description.

The primary care home links physician practices to a network of health care professionals. This linkage will be more formal than it has been for some physicians. A primary care home describes patient medical homes - or networks of patient medical homes - linked with health authority and community agency primary care services that form the foundation of a coordinated system of primary and community care within the community. This team-based approach includes other health professionals working together with family doctors, forming networks of care. We heard from physicians during our Visioning consultation that this is something they want to see – both for the benefits for patients and also to enable more of a work-life balance for doctors. Click here for a full description.



Why do we need change to the primary care system, and why does it need to be done so quickly?

We have made a lot of progress in building a stronger primary care system over the last decade, in particular through the A GP for Me initiative over the last three years.

Even with our achievements over the last few years, there are still too many patients who cannot access continuous, coordinated primary care, and family physicians find it difficult to get support for increasing numbers of patients with complex health conditions.

And our population is aging and growing. We expect the patient medical home and primary care home models will help doctors get support for increasing numbers of patients with complex health conditions. We want to create a clear path to care so that:

  • Patients get the right care, in the right place, at the right time.
  • More patients can access care more easily, as teams or networks of care support both patients and their doctors.
  • We can meet the needs of a changing physician workforce.



As a physician, I don’t think this is really changing what I am doing. I feel that I am already doing these things. What is new about this?

In BC, many family physicians and communities are already well on their way to establishing patient medical homes and/or primary care homes. This is a continuation of changes that have been taking place in the primary care system over the last decade. Most recently through the A GP for Me initiative, but also through the residential care initiative, the GPSC fee incentives, and many other programs and initiatives targeted to strengthen primary care.

Now, we want to support all GPs to reach the next level – to achieve the attributes of the patient medical home, to formally link with other health care professionals as a team, and to enhance your capacity to take on new patients while enabling you to achieve or sustain a healthy work-life balance.



What do these changes in practice mean for me as a family physician? How will they benefit me?

Doctors told us through our 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. And we know newer doctors expect to practice in different ways than more experienced doctors.

With the support of teams and networks of other health professionals, family physicians can provide patients with the right care, in the right place, at the right time, while also looking out for their own health and wellness, and professional satisfaction.

This includes helping divisions and doctors create healthy and vibrant work environments, and therefore assist with recruitment.

How will it benefit patients?

Our patients will have an easily understood, recognizable, coordinated system of care in their communities that places them and their families firmly at the centre of care.



What is the funding available for divisions to support doctors in adopting the patient medical home model, and working with health authorities on establishing links to primary care homes?

The GPSC confirmed the overall funding allocation at up to $250,000 per 34 divisions to resource the divisions’ patient medical home/primary care home development and change management work. The funding is available for each division that applies, based on need and readiness. For application templates and criteria, please email Community Partnerships and Integration (Divisions@doctorsofbc.ca).



What’s the status on the proof of concept communities?

While the GPSC wasn’t involved in the initial selection of the phase 1 communities, GPSC and staff have been supporting divisions in the work. The GPSC is aware of five communities that are considered ‘active’: Thompson Region, Mission, Central Okanagan, Fraser Northwest, Kootenay-Boundary. Work with additional communities is expected to begin in the spring.



What’s the latest information on the nurse-in-practice models?

Currently, the ministry is working with Doctors of BC to work out details of contracts relating to nurse-in-practice models. The GPSC continues to identify the needs for both practice readiness and relationships for implementation.



Why am I being told that I need to assess my patient panel?

GPSC has identified that understanding the patient panel is foundational in order to achieve the attributes of the patient medical home. Understanding your patient panel and patient population can improve proactive planned care, and can also help better assess the needs of a practice. The GPSC has support available to help physicians with this work. For further information, please email Community Practice and Quality (PSP@doctorsofbc.ca).