1. Patient Medical Home Attribute: Commitment
A PMH will ensure that patients have access to a personal family physician who will be the most responsible provider (MRP) of his or her medical care. Physicians have a defined patient panel and patients and physicians have a shared understanding of their mutual therapeutic relationship
Examples in our community:
existing longitudinal family practices
physicians accepting care for high-needs unattached patients in our community
Physician & patient contracts
What do I need for my practice:

2. Patient Medical Home Attribute: Contact/Timely Access
Patients are able to access their own family physician or PMH team on the same day if needed. Patients know how to appropriately access advice and care on a 24/7 basis
Examples in our community:
Advanced access practices (same day appointments)
3rd next available appointment tracking
What do I need for my practice:

3. Patient Medical Home Attribute: Comprehensive Care
The PMH provides deliver of, and linkages to comprehensive services. The specific comprehensive services provided through the PMH and network of PMHs are determined by context, considering both community need and also available resources.
Examples in our community:
Existing longitudinal family practices
hospitalists working with community GPs to communicate goals of care (admission notification)
What do I need for my practice:

4. Patient Medical Home Attribute: Continuity of Care
Longitudinal relationships support patient care across the continuum of patient care, spanning all settings. The enduring relationship between the patient, family physician and PMH team is key, and needs to be supported by informational continuity (two way communication that informs appropriate and timely care)
Examples in our community:
Existing longitudinal family practices
Communication between family physicians and specialized services (hospitalist, maternity)
What do I need for my practice:

5. Patient Medical Home Attribute: Coordination of Care
The PMH is the hub for the coordination of care through informational continuity and personal relationships and networks with other PMHs, inter-professional team members within and linked to the practice, and linkages to speciality and specialised services across the care domains.
Examples in our community:
Existing longitudinal family practices
Pathways providing information on specialists and other resources in our community
Relationships between Specialists and Family Physicians
FNW Referral Hub (attachment, psychiatrist, UBC Pharmacy, Nurse Debbie, NP)
What do I need for my practice:

6. Patient Medical Home Attribute: PMH Networks Supporting Communities
The PMHs are networked through the Divisions of Family Practice (or other similar community care service organizations where Divisions may not exist) to enable better coordination, partnership and integration with health authority and non-governmental community services (PCH), and the broader system of health care
Examples in our community:
Existing longitudinal family practices
NP Primary Care Clinic
Aunt Leah’s Primary Care Clinic
Spirit of the Children Primary Care Clinic (Aboriginal Health)
Hospitalist Program
What do I need for my practice:

7. Patient Medical Home Attribute: Family Physician Networks Supporting Practice
Family physicians are part of a clinical network working together to meet the comprehensive care needs of their patients and the patients of other PMHs in the community including extended hours of service, cross coverage and/or on-call
Examples in our community:
Residential Care Initiative
maternity care clinics
Palliative care program
walk-in clinics providing urgent care
Sunshiner’s frail elderly homebound patient GPs
Hospitalist programs
What do I need for my practice:

8. Patient Medical Home Attribute: Team Based Care
The PMH generally includes more than one FP working with an expanded inter-professional team within the practice, and/or liked to the practice, with a focus on on person-focused relationship-based care. Providers within the practice are working to optimized scope
Examples in our community:
home health supports for vulnerable populations
FNW visiting Psychiatrist consultations (Dr. Sandhu)
Nurse Debbie
NP for frail elderly patients
UBC visiting pharmacist program
What do I need for my practice:

9. Patient Medical Home Attribute: Information Technology Enabled
Physicians, providers, and staff in the practice are IT enabled, including optimized EMR use and data collection methods to inform quality improvements in patient care and practice workflow.
Examples in our community:
Excelleris information transfers from FHA
Pathways in practice (resources, pearls, referrals)
Small group EMR networks
What do I need for my practice:

10. Patient Medical Home Attribute: Education, Training and Research
The PMH promotes mentoring, peer coaching for continuing professional development, training and research.
Examples in our community:
UBC Residency Program
UBC CME programs
PSP Small Group Learning Sessions
Program mentorship (RCI, Maternity)
PSP Modules
CARES Frail Elderly Project
What do I need for my practice:

11. Patient Medical Home Attribute: Evaluation and Quality Improvement
Physicians, other providers in the PMH, and patients are involved in clinical quality improvement activities at a professional, practice, community and system level
Examples in our community:
Practice Support Programs (PSP)
Division program evaluation (Shared Care, GPforMe, Residential Care, Patient Medical Home, Primary Care Home)
Health Data Collaborative (HDC)
CARES Frail Elderly Project
What do I need for my practice:

12. Patient Medical Home Attribute: Internal and External Supports
The PMH has a business model which supports longitudinal, comprehensive, coordinated, team-based care, and linkages with specialized services.
Examples in our community:
Mobile Falls Prevention Clinic
Speech clinic
Division Interpretation service
STI Clinic
Breastfeeding education & support
Umbrella New Canadian Clinic
GPSC fees for CDM and complex care
iConnect Health center for diabetes
Purpose Clinic
NP frail elderly program
HIV clinic STOP
Dr. Sandhu Psychiatry visits
Child Health clinics for immunization
UBC Pharmacy program
Fluoride varnish clinics oral health assessment
MSK sports medicine clinic
Nurse Debbie program
Seamless perinatal supports
Community Respiratory services
Vulnerable women in their childbearing years and their infants seamless perinatal model of care
Breathewell
What do I need for my practice:

13. I am interested in being an early adopter

14. I would be interested in the PMH once a few proof of concepts have completed their work and there are case studies