The medical home

Primary care in BC desperately needs to be improved. We require a mechanism to attract capital resources to build the appropriate infrastructure necessary to provide bona fide medical homes for our patients. The medical home model, which we all theorize about, must have physical space to accommodate 15 to 20 family doctors as well as many nurse practitioners, registered nurses, and support staff to adequately provide 24/7 comprehensive primary care to our dedicated patients. This structure should provide acute care services, which are now only available in overcrowded hospital emergency rooms, thus helping to decongest emergency rooms in the province. Well-organized public-private partnerships can supply needed financial resources to build these structures without either government or physician capital outlay. We need government leadership to make this happen. 

Once built, medical homes need to have an organizational plan in place to accommodate the family of providers needed to supply primary care services on an expanded basis. There must be concise and clearly defined deliverables, and providers need to be accountable to their patients to provide all specified primary care services. There must be appropriate financial incentives available so that family physicians will adopt the model and take on the leadership necessary to make the model successful. We need government leadership to make this happen.

As well, there must be a contractual arrangement between patients and health providers to make sure that a patient will use the medical home to which he or she is attached. There can be no organizational congruency or financial savings if patients just go wherever they want to receive primary care services. We need government leadership to make this happen. 

Presently family doctors often work in small and isolated groups. We own and operate a myriad of walk-in clinics. We try to get locums with little or no success. We often do not provide after-hours or weekend clinics to our patients because we just cannot stretch ourselves any thinner. We often do not perform suture repair and wound care, fracture care, or any acute-care service in our under-equipped little nests. Sometimes we leave our little office to work walk-in clinic shifts elsewhere because the money is better there! There is no good mechanism to draw nurse practitioners into the provider equation. Emergency rooms are so overrun with patients who do not really need to be there that the emergency room staff have difficulty managing the real emergencies. Every one of these issues could disappear if primary care were reinvented along the lines of infrastructure development, organizational planning, and contractual reality, which is outlined above.

My points represent only the barest framework upon which to build a firm and useful structure, but the three points are critical in order to build the best one. We need to actually start to make change happen before family medicine implodes in a puff of smoke in BC.
—Robert H. Brown, MD, CCFP
Sidney, BC