Patient Medical Home Attributes: Key Components for Quality Care
Ensuring access to a personal family physician, timely care, comprehensive services, continuity of care, and care coordination are essential elements of a Patient Medical Home (PMH). These attributes support holistic and integrated patient care, fostering lasting relationships and effective communication between patients and their healthcare providers.
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Presentation Transcript
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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: Division Interpretation service GPSC fees for CDM and complex care NP frail elderly program Dr. Sandhu Psychiatry visits UBC Pharmacy program MSK sports medicine clinic Nurse Debbie program Community Respiratory services Breathewell Mobile Falls Prevention Clinic Breastfeeding education & support iConnect Health center for diabetes Child Health clinics for immunization Fluoride varnish clinics oral health assessment Seamless perinatal supports Vulnerable women in their childbearing years and their infants seamless perinatal model of care Speech clinic STI Clinic Umbrella New Canadian Clinic Purpose Clinic HIV clinic STOP What do I need for my practice:
I would be interested in the PMH once a few proof of concepts have completed their work and there are case studies
