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

By the end of 2016, the goal is to have every full-service family practice in Prince George provide team-based care modelled on the PCH.  In 2015, this reached a major milestone when the city’s first two inter-professional teams were put in place, serving 11 practices and 33 family physicians caring for 30,000 patients. By the end of 2016, the final three teams are expected to be up and running, making all 33 Prince George practices primary care homes.


  • The practices operate on fee-for-service funding, with inter-professional teams provided by Northern Health. Each patient has a primary care provider.
  • Prince George is a site of the UBC family medicine residency program and many practices also provide teaching for medical students from the Northern Medical Program.
  • Practice physicians also provide care in the city’s after hours clinic, as well as primary care in inpatient and residential care facilities.
  • For some patients, the family physician will work with the inter-professional team to create a care plan that includes information about the patient’s history, treatment, care preferences, goals, barriers to care etc. With the patient’s permission, the plan can be uploaded to Northern Health’s electronic records so that the information is easily accessible if the patient needs emergency or inpatient care in the hospital. Approximately 10 per cent of patients require care plans.


  • The patient population mirrors the city’s population and includes increasing number of older patients requiring more frequent visits and more complex care.

Team Members

  • The inter-professional team 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 are to be added.


  • 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.


  • The team-based approach is especially beneficial to 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, making it easier for them to connect with a health care provider when they need assistance or have a question.
  • The coordinated, team-based approach provides better continuity of care and follow up for patients.
  • In the ideal world, the inter-professional team members would be co-located with the physicians.

Advice for family physicians contemplating team-based care

  • The PCH model in Prince George was made possible and co-designed as a result of the aligned vision for primary care shared by the physicians in the Division of Family Practice and Northern Health.
  • It takes time to create meaningful partnerships between independent physicians in the community and the highly structured environment within a health authority. There’s lots of cross-learning involved.
  • Going forward with PCH, it’s important to have high quality data for evaluation.
  • It’s important for physicians to understand all that is entailed with providing a Patient’s Medical Home.
  • Physicians need to trust in the abilities of the other members of the team, understand their abilities and comfort zones, and try to avoid micro-management.
  • You can make this model work within a fee-for-service environment, but ultimately change in funding models is optimal.

Our thanks to Dr. Garry Knoll, physician lead, and Ms. Olive Goodwin, executive director of the Prince George Division of Family Practice for providing this information (June 2016).