Building your medical home

Research has shown that building a trusting relationship with patients over time, together with coordinated care by health teams, can produce better health outcomes. The PMH model leads to enhanced care, higher satisfaction for both patients and providers and even decreased costs to the healthcare system. For patients, having a PMH means benefiting from well-coordinated, accessible, comprehensive team-based patient and family-partnered care, led by family physicians and their teams.

Patient defined practices

Ann Makin, the PCN’s Evaluation & Practice Improvement Consultant, is laying the groundwork by facilitating work with PCN member clinics in the Bow Valley. She says, “The College of Family Physicians of Canada characterizes the PMH as a family practice defined by its patients as the place they feel most comfortable – most at home – to present and discuss their personal and family health and medical concerns.”

Ann guides small teams from participating clinics through the steps which include an extensive process assessment and then implementation of actions addressing opportunities and gaps. Ideally, clinic teams have functional representation including a physician ‘champion’, clinic manager, nurse, front desk and referrals. “The richness and depth of team discussions are impressive and give the greatest insights and commitment to improvement,” she explains. “The idea is to incorporate these standardized procedures into the clinic’s normal way of working.” So far two clinics in Canmore are engaged in the process, while discussions are underway with three more in Canmore and one in Banff.

Collaborative services

A foundational element of the PMH initiative and best practice patient care is panel management, which has been a focus with physicians and clinics for some years. This involves analysis of every physician’s panel list, confirming that every patient is aware of who their family doctor is and verifying this with the clinic’s records. Once this is done, the clinic can become central to all the patient’s healthcare needs: community care, specialist referrals and follow up, plus services provided collaboratively through clinic and PCN nursing staff as well as other PCN health professionals: a dietitian, active living consultants, a pharmacist and behaviour change specialist.

Ann adds, “It is encouraging to see a team’s willingness to embrace quality improvement and change. Also, as patients realize how the PMH approach can bring personal rewards in quality of care, they too can participate in building relationships by collaborating consistently with their medical team. ”