Introduction

Introduction

The concept of a "medical home" is gaining momentum in many countries. This is defined as a patient-centred medical care setting that includes the following features: 1) patients have a personal family physician who provides and directs their medical care; 2) care is for the patient as a whole; 3) care is coordinated, continuous and comprehensive with patients having access to an inter-professional team; 4) there is enhanced access for appointments; 5) the practice includes well-supported information technology, including an electronic medical record; 6) remuneration supports the model of care; and 7) quality improvement and patient safety are key objectives. The medical home acts as the central hub for the provision and coordination of the medical care services needed by each of its patients.

Across Canada, governments working together with family physicians, nurses and other health professions have implemented a number of primary care reform initiatives, such as Primary Care Networks in Alberta, Family Health Teams in Ontario and Family Health Centers in Prince Edward Island. Many of these approaches offer features similar to a medical home but remain poorly understood by the public. Many of them include the core elements of a "medical home", and in fact some are now referring to them as "medical homes" (Health Council of Canada, 2009b; Canadian Institute for Health Information, 2009). The "medical home" concept brings the components together under a more completely developed strategy with a more patient-centred focus. It should be noted here that we are not recommending that the various primary care models being introduced throughout Canada should be renamed "medical homes". But we are recommending that each of these should aspire to serve as a medical home for its patients.

The CFPC recommends the introduction of the medical home concept for the people of Canada – incorporating the strengths of medical home models elsewhere meshed with the lessons learned from primary care renewal experiences across Canada. By adopting this patient-centred concept and language, we have an opportunity to help Canadians better understand at the primary care initiatives being introduced across the country are focused on what is best for them and not just for the system or its providers. By setting a goal for every practice to try to become a "medical home" for its patients we could develop something uniquely Canadian that will ensure patient-centred care with improved access and better health outcomes for all people throughout our nation. Increased support from all stakeholders will be required, however, to help Canadians achieve the full potential of our primary care initiatives – to build on the successes being realized and "bring them on home."

1 1 Concepts collected from several sources, including: Berenson et al, A House Is Not a Home: Keeping the Patient at the Center of Practice Redesign, Health Affairs, Vol 27, No 5, September / October 2008..

 

Definition

The CFPC defines a Canadian medical home as:

A medical office or clinic where each patient would have:

i. Her or his own family doctor
ii. Other health professionals working together as a team with the patient's own family doctor
iii. Timely appointments for all visits with the family doctorand with other primary care team members
iv. Arrangement and coordination of all other medical services, including referrals to consulting specialists
v. An electronic medical record

The medical home would include:

i. Appropriate funding and resources
ii. Necessary system supports for ongoing evaluation and quality management

Primary Care Teams in Canada

The following is an overview of some of the primary care initiatives across Canada:

British Columbia
Integrated Health Network (IHN): BC launched 26 IHNs in November 2008. They currently serve a patient population of 50,000. "Teams within Integrated Health Networks target patients with mental health conditions and addictions, patients with two or more chronic conditions, or patients who reside in underserved communities" (Health Council of Canada: British Columbia Perspective, 2009a).

Patients are enrolled through their family physician and are cared for by teams that vary depending on patient needs. A patient's team includes family physicians and may include nurses, mental health specialists and pharmacists (Health Council of Canada: British Columbia Perspective, 2009a).

Interdisciplinary primary health care teams in BC, ranging in size from three to 20 providers, are typically led by a family physician and are comprised of a variety of health care providers (Health Council of Canada: British Columbia Perspective, 2009a).

The BC Primary Health Care Charter, published in 2007, sees patients as partners in primary care reform.

Alberta
Primary Care Network (PCN): Comprised of physicians, nurses, pharmacists, dieticians and other front line providers, there are currently 30 PCNs in Alberta. Approximately 60 percent of family physicians belong to aPCNwith a goal to increase that figure to 80 percent by 2011 (Ward, 2009).

PCNs improve patient care and access and are able to accept more patients. According toWard (2009), nearly two million Albertans (Alberta has a population of about 3.65 million) have access to a family physician through a PCN.

Saskatchewan
Primary health care teams include a variety of health care providers such as family physicians, nurse practitioners and social workers. According to the Health Council of Canada (2009a): "In smaller communities a team may consist of a nurse practitioner working in collaboration with an off-site physician who may provide visiting services once or twice per week" (Saskatchewan Perspective, p. 1).

Saskatchewan's Patient First Review allows for public consultation on health care system policy.

Manitoba
Physician Integrated Network (PIN): Are being established to expand "interdisciplinary care in fee-for-service group practices" (Health Council of Canada: Manitoba Perspective, 2009a, p. 1).

PINs seek to improve the delivery of primary care by: improving access; improving providers' access to patient information; improve providers' work life; offer high-quality primary care with a focus on chronic disease (Health Council of Canada: Manitoba Perspective, 2009a).

About 9 percent of Manitoba's family doctors have joined the PIN and 65 more doctors are being recruited.

Ontario
Family Health Teams (FHT): FHTs are interdisciplinary teams with size and composition based on community needs and provider availability (Health Council of Canada: Ontario Perspective, 2009a). Led by family physicians, FHTs are generally composed of 10 primary care physicians and seven other health care providers; but teams can range in size from one physician to 50, and large networked FHTs may include 116 physicians.

There are currently 150 FHTs in Ontario with plans to expand by another 50. Approximately 1.9 million Ontarians belong to a FHT; 250,000 of whom did not previously have a family physician (Health Council of Canada: Ontario Perspective, 2009a).

Community Health Centres (CHC): CHCs also offer interdisciplinary care with physicians, nurse
practitioners, social workers, etc. providing primary health and health promotion programs. CHCs "improve primary health care by targeting specific populations. These include high-risk or vulnerable populations…" (Health Council of Canada: Ontario Perspective, 2009a).

Family Health Networks (FHN) and Family Health Groups (FHG) "are made up largely of groups of physicians who work together to deliver comprehensive care to their patients. These practices provide after-hours access to a nurse through a telephone advisory service" (Health Council of Canada: Ontario Perspective, 2009a).

Quebec
Family Medicine Group (FMG): An FMG is a team typically comprised of a family physician and a nurse and other health care providers based on community need. The Quebec government plans to have 300 FMGs throughout Quebec with the entire population registered with a family medicine group physician (Ministère de la Santé et des Services sociaux, 2009). Quebec has recently launched the next generation of its primary care strategy, Integrated Network Clinics, again, modeled on team-based care.

New Brunswick
Community Health Centres (CHC): A core team of a physician, nurse practitioner and a nurse can be complemented with other health care providers based on community need. CHCs "provide health promotion and illness/injury prevention services, chronic disease management, and a focus on the broader determinants of health such as employment, education and poverty" (Health Council of Canada: New Brunswick Perspective, 2009a). There are seven CHCs in New Brunswick.

Health Service Centres (HSC): HSCs are physicians' offices complemented with nurse practitioners and nurses.

Nova Scotia
Family physicians working with either a nurse practitioner or a family practice nurse form a typical primary care team. Dieticians, social workers and other health care providers can be added depending on community need (Health Council of Canada: Nova Scotia Perspective, 2009a).

Prince Edward Island
Family Health Centres (FHC): There are five family health care teams in PEI, which include at least one family physician working with a nurse practitioner or an advanced practice nurse (Health Council of Canada: Prince Edward Island Perspective, 2009a). These teams may include other health providers such as mental health counsellors, depending on community need.

Other teams in PEI include: primary health home care teams; integrated palliative care teams; public health teams; and, community mental health and addiction teams.

A recent review of FHCs set a goal to "broaden existing teams, by expanding the number of physicians working in teams and adding other providers when possible" (Health Council of Canada: Prince Edward Island Perspective, 2009a).Asixth and seventhFHCare being established in rural PEI.

Newfoundland and Labrador
Primary care teams, with a lead family physician working with nursing staff, community health staff and a social worker, are geographically defined; that is, these teams serve all people within a given area (Health Council of Canada: Newfoundland and Labrador Perspective, 2009a).

Other providers can be part of the team and are added as needed and when available.

Currently, the government of Newfoundland and Labrador is planning 30 team areas to serve the entire population of the province (Health Council of Canada: Newfoundland and Labrador Perspective, 2009a).

Yukon
In Whitehorse, the Diabetes Collaborative is a team of family physicians, nurses, physiotherapists and nutritionists managing patients with diabetes. The family physician is typically the clinical leader.

In rural and remote regions of the territory, teams typically consisting of a physician and a nurse, work collaboratively but are not always co-located (Health Council of Canada:Yukon Perspective, 2009a).

Northwest Territories
Integrated Service Delivery Model (ISDM): The ISDM serves the general population but some teams target specific patient groups, such as people with diabetes. The ISDM coordinates care and targets "service and system integration, from primary community care to secondary and tertiary levels of service…[it is a] team-based, client-focused approach to provid[ing] health and social services" (Health Council of Canada: NorthwestTerritories Perspective, 2009a).

Nunavut
Nunavut suffers from a lack of health care providers, but typically, the community health nurse leads an interdisciplinary team and is the first point of contact for patients. "Different health care providers can be on a team at any given time, depending on the circumstances and whether team members are on location, visiting, or virtual" (Health Council of Canada: Nunavut Perspective, 2009a).

The Northern Medical Unit has physicians on call, such as consultant specialists in Winnipeg, who can consult by telephone or email and some communities such as Baffin, Kivalliq and Kitikmeot have physicians, physiotherapists and others visit these communities regularly (Health Council of Canada: Nunavut Perspective, 2009a).

The core team in community health centres is usually comprised of two community health nurses, a social worker, community health representatives, clerk interpreters, and an X-ray technician (Health Council of Canada: Nunavut Perspective, 2009a).