The patient medical home: Working together to create an integrated system of care

Issue: BCMJ, vol. 59, No. 1, January February 2017, Pages 15-17 Family Practice Services Committee

Moving toward an integrated system of care means creating a health care system that improves support for patients—particularly vulnerable patients—through enhanced and simplified linkages between providers.

Moving toward an integrated system of care means creating a health care system that improves support for patients—particularly vulnerable patients—through enhanced and simplified linkages between providers. The patient medical home model is an important component in building this system. But what does this look like in practical terms?

What is a patient medical home?
A patient medical home is a longitudinal GP practice in which doctors are supported to practise with the support of a team as part of a team (Figure), which may include nonphysician health care professionals such as nurse practitioners, nurses, social workers, pharmacists, and dietitians. The patient medical home is networked with other practices, and these practices and networks are linked to additional health care services provided outside of the practice. By working within their practice and networking with other physicians and health care providers, physicians are better enabled to deliver or enhance access to a broad range of services for their patients.

The overall concept of the patient medical home comes from the College of Family Physicians of Canada (CFPC), which describes the pillars of a patient medical home.[1] The College describes the patient’s medical home as “the patient-centred family practice identified by its patients as the place that serves as the home base or central hub for the timely provision and coordination of all their health and medical care needs.”[2] The CFPC’s initiative builds a vision for the future of family practice in which every family practice across Canada delivers care that is patient-centred, encompasses patients at every stage of life, and is linked to other health services. Through this model, patients are ensured the best possible outcomes through their family physician’s collaboration with a team or network of providers.[2]

In BC the GPSC has adapted this model and included two additional attributes, influenced by the existence of divisions of family practice. Divisions can enable linkages between GP practices, creating a network of care. Additionally, through representing the local community network of physicians, divisions are influencing the broader design of the integrated system of care in response to local health care needs identified in their communities.

Variations on the patient medical home model—including Ontario’s family health teams and Alberta’s primary care networks—have been implemented across North America and internationally.

The patient medical home model in Ontario 
The patient medical home model in Ontario is realized through family health teams. Since 2005 Ontario has implemented 184 family health teams across 200 communities, which currently serve over 3 million patients.[3] The composition of the family health team is flexible, based on local health and community needs, and includes family physicians and a multidisciplinary team of other health professionals like nurse practitioners, nurses, social workers, and dietitians.[3] Family health teams provide a wide range of services and coordinate care provided by specialists and community providers.[4]

The patient medical home model in Alberta
Alberta’s primary care networks are groups of family physicians working with other health care professionals to meet the needs of their local community—essential attributes of the primary care home model. There are 42 primary care networks in the province, consisting of approximately 3800 physicians and the full-time equivalent of 1000 other health care providers such as nurses, dietitians, and pharmacists, delivering primary care services to approximately 3.5 million Albertans. Primary care networks emphasize health promotion, disease and injury prevention, and care of patients with complex or chronic diseases. They also work to improve the coordination of primary care with hospital, long-term, and specialty care.[5]

The patient medical home model in BC
The GPSC’s vision is to enable access to quality primary health care that effectively meets the needs of patients and populations in BC, using the BC patient medical home as the foundation for delivery, linked with a broader, integrated system of primary and community care. Creating an integrated system of care involves a reorientation of some health care services—developing improved linkages between patient medical homes, networks of patient medical homes, and outside services provided by health authorities. As the GPSC works to develop and support the patient medical home model, health authorities are working to streamline the specialized services they provide, starting with services for frail older adults with complex medical issues and patients with mental health and substance use issues.

Much of this work is being built on a foundation of innovations and solutions created through divisions’ work on A GP for Me—like the Martin Street Outreach Clinic in Penticton. The clinic, a partnership between Interior Health and the South Okanagan Similkameen Division of Family Practice, takes a team-based approach to mental health and substance use care. Family doctors provide primary care while a social worker offers patient education and facilitates engagement with local services and professionals in the community to link patients with critical supports such as housing. Other professionals provide case management, counseling, diabetes education, and other services. Once patients are stabilized at the clinic, they are connected with a family physician in the community. If a community option is not available or appropriate, patients are able to receive care at the clinic on an ongoing basis.

As of March 2016, in just under 1 year of operation, the clinic supported more than 500 patients who did not previously have a family doctor, and the clinic social worker made more than 400 patient referrals to community services—a great example of team-based care work between family physicians, multidisciplinary partners, and health authority services that supports the patient medical home model.

Through the move to the patient medical home model, the GPSC’s goals are to:
•    Increase patient access to appropriate, comprehensive, quality primary health care for each community.
•    Improve support for patients, particularly vulnerable patients, through enhanced and simplified linkages between providers.
•    Contribute to a more effective, efficient, and sustainable health care system that will increase capacity and meet future patient needs.
•    Retain and attract family doctors and teams working with them in healthy and vibrant work environments.

The GPSC is working to clear the path to care by creating smoother connections for family doctors—through patient medical homes—to teams of health professionals, networks, and better-coordinated specialty services in the community.

By working together in new ways, the GPSC and its partners can better:
•    Meet the needs of patients now and into the future, so patients have timely access to continuous, coordinated primary and community care across practitioners and locations. 
•    Manage the impacts of a changing workforce—resulting from retiring GPs and work practices of new GPs—so we can continue to deliver care effectively and keep up with patient demand for access.
•    Establish strong, healthy, and affordable health care for the future.

This also supports physicians in a number of ways. Through patient medical homes, and with the support of teams and networks of health professionals and strong links to the community:
•    Family physicians know their patients are getting the right care, in the right place, at the right time.
•    Responsibility for patient support won’t rest on one physician’s shoulders. Pressures are eased, so physicians can achieve better work-life balance and look out for their own wellness too.
•    Divisions and family physicians can create healthy and vibrant work environments that will also attract new doctors.

As this is a multiyear endeavor, the GPSC has committed to supporting targeted implementation of the work in phases in order to support its partners—specifically physicians and divisions of family practice—to manage the workload. Work currently underway includes understanding current health needs in a community, engaging and moving toward the patient medical home model, aligning GPSC programs and initiatives to support patient medical homes, identifying barriers and working on a provincial level to address these, and developing implementation guidelines and supporting tools and resources.

For more information on the patient medical home in BC, visit 
—Brenda Hefford, MD 
Executive Director, Community Practice, Quality and Integration, Doctors of BC


This article is the opinion of the General Practice Services Committee and has not been peer reviewed by the BCMJ Editorial Board.


1.    College of Family Physicians of Canada. What is the patient’s medical home? Accessed 22 December 2016.
2.    College of Family Physicians of Canada. A vision for Canada. Family practice: The patient’s medical home. Accessed 22 December 2016.
3.    Ontario Ministry of Health and Long-Term Care. Family health terms. Accessed 22 December 2016.
4.    Rosser WW, Colwill JM, Kasperski J, Wilson L. Patient-centered medical homes in Ontario. N Engl J Med 2010;362:e7. 
5.    Alberta Health. Primary care networks. Accessed 22 December 2016.

Brenda Hefford, MD. The patient medical home: Working together to create an integrated system of care. BCMJ, Vol. 59, No. 1, January, February, 2017, Page(s) 15-17 - Family Practice Services Committee.

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