How can we create a Patient’s Medical Home (PMH) for our patients? Are there aspects of our practice that already support a medical home model? What might we need to do differently? How will the funding work? How will we know if our medical home model is making a difference?

Family physicians have many questions. The BCCFP recognizes the need for more information about the clinical and business implications of operating a team-based family practice within the network of services of the Primary Care Home (PCH) or PMH.

This special issue of PRIME e-newsletter looks at two existing examples of team-based care in BC and highlights some of the PMH resources provided by the College.

Advocating for the Patient’s Medical Home

For the past five years, the CFPC has been advocating for the PMH as a vision for the future of family practice across Canada. As a result, there are now multiple resources for physicians, including a useful self-assessment readiness tool and a series of best advice guides. The 10 pillars for transforming a practice into a PMH form the basis for the Doctors of BC vision of primary care and are closely aligned with the attributes of the PCH.

BCCFP is actively involved in information sharing and advocacy for PMH at the provincial level. As BC is now moving forward with plans to initiate team-based primary care province-wide, BCCFP is joining the General Practice Services Committee (GPSC) PMH Implementation and Design Team. BCCFP President Dr. Christie Newton will also be making a presentation on PMH and quality improvement to the BC Ministry of Health’s Select Standing Committee on Health.

“The CFPC has resources and experience that can help BC’s family physicians and health care leaders transition to PMH models within the Ministry’s provincial Primary Care Homes,” Dr. Newton says. “We will work closely with the GPSC to share what we have learned through other provinces’ experiences with PMH implementation. We will also continue to work to identify any continuing education needs related to team-based care and practice management.”

Primary care homes in Prince George

For more than five years, the Prince George Division of Family Practice has been working with Northern Health toward the target of offering all of the full-service family practices in the city access to an inter-professional team, enabling a full PCH service delivery model.

In 2015, this reached a significant milestone when the first two inter-professional teams were put in place, serving 11 practices and 33 family physicians who care for 30,000 patients. By the end of 2016, a further three teams are expected to be up and running, making all 33 Prince George practices primary care homes.

The inter-professional teams are provided by Northern Health. Members include primary care nurses, mental health clinicians, social workers, physiotherapists and occupational therapists, as well as paraprofessional supports, such as life skills workers. Public health nurses will be added soon.

Dr. Garry Knoll’s practice is one of 11 currently serving patients with a PCH/PMH model.  It’s also a teaching practice, with residents from the UBC Family Practice Program and medical students from the Northern Medical Program. He stresses that it’s important for new family physicians to learn how to work in teams and receive exposure to team-based care.

Dr. Knoll notes that the team-based approach is especially beneficial for patients that require a greater level of care, including the frail elderly or patients with chronic health problems.  Patients are given a first point of contact on the team – either the primary care provider or another member of the team as appropriate – making it easier for them to connect when they need assistance or have a question.

Care plans provide easy access to patient information

To enhance care for more complex patients, the patient’s primary care physician (with input from other team members) creates a care plan that includes information about history, treatment, care preferences, goals, barriers to care, etc. With the patient’s permission it can be uploaded to Northern Health’s electronic records so that the information is easily accessible if the patient needs hospital care. Practice physicians also provide primary care in the city’s inpatient and residential care facilities.

Dr. Knoll finds that the coordinated, team-based approach provides better continuity of care – he has a better sense of how his patients are progressing and more confidence that they will receive suitable follow-up. However, he notes that physicians need to trust in the abilities of the other members of the team.

“There are many balls in the air that need to be looked after, but with this model you are not the only one keeping the balls in the air,” he says.

The practices use the same EMR MOIS format as the Northern Health inter-professional teams, making it easier to share care plans. Team communications are managed using secure texts, phone calls, fax, patient rounds and joint patient team meetings. In the near future, secure EMR to EMR messaging will also be an option.

Prince George Division of Family Practice Executive Director Ms. Olive Godwin credits the aligned vision between the Division and Northern Health with the progress in Prince George – the two were able to work together to co-design a PCH approach that worked for both the family physicians and the health authority. However, she stresses that it takes time to create meaningful partnerships between independent physicians in the community and the highly structured environment within a health authority.

With the teams provided by Northern Health, the Prince George PCH practices are currently operate on a fee-for-service model. Physicians from the practices also provide care at the city’s after hours clinic.

For more information about the PCH initiative in Prince George, look for practice profiles on the BCCFP PMH page.

Team-based care in Vancouver

The UBC Family Practice Centre in Vancouver is a teaching practice that supports the education of family medicine residents as well as serving patients. (Formerly at the Children’s & Women’s site, the centre is now located in the Fairmont Building on West Broadway.)

The centre has 10 family physicians (operating eight separate practices within the centre) and three nurse practitioner practices. (Two of the nurse practitioners provide care for unattached cancer survivors who have completed treatment at the BC Cancer Agency.) The team also includes a dietician. Although there is no pharmacist , the practice provides collaborative care with local pharmacies.

It’s one of the BC practices receiving population-based funding as part of the BC Ministry of Health’s Primary Health Care Organization (PHCO). The PHCO brings physicians, nurses and other allied health professionals together in group practice settings. The Centre receives an annual funding payment for each patient based on the patient’s need for care, and this payment is reduced if patients seek primary care services elsewhere, e.g., walk in clinics.

Dr. Sajjan explains that this is an incentive for the clinic to meet patient needs for urgent care. Each practice takes turns at being  “doctor of the day”  in addition to staffing a urgent clinic on Saturday and taking call along with residents. Most of the physicians also provide home visits. In general, physicians who do not provide maternity care refer their patients to a colleague within the practice. However, some patients opt for external midwifery care.

Population-based funding provides flexibility

The funding provides more flexibility than fee-for-service, including the ability for practitioners to handle some patient questions by phone. Patients can also see other team members as needed, such as for well woman or urgent appointments.

The team communicates about patient care via the EMR, and it’s possible for physicians to access patient records remotely when they are on call.

Dr. Sajjan notes that there are many advantages for physicians working in a team within the population-based funding model. These include: increased job satisfaction, more time for teaching and the reassurance that your patients are well-looked after in your absence. The model is also popular with patients: “Patients do their very best to stay in our clinic,” she notes. “The continuity of care is huge, and it’s an advantage for patients to be able to be able to talk to their doctor on the phone.”

For more information about team-based care at the UBC Family Practice Centre, look for practice profiles on the BCCFP PMH page.

Are you working in a PMH?

If so, we are collecting information to help us to create future PMH resources and would like to hear from you. Please send an email to

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