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New Best Advice Guide on Health Literacy Released

New Best Advice Guide on Health Literacy Released

The latest Best Advice Guide on the topic of Health Literacy supports the crucial first pillar in the Patient’s Medical Home (PMH), Patient-Centeredness. This guide explores ways in which family phy...


The Patient’s Medical Home (PMH) is a vision for the future of family practice in Canada. In this vision, every family practice across Canada offers the medical care that Canadians want — seamless care that is centred on individual patients’ needs, within their community, throughout every stage of life, and integrated with other health services.

  • Patients receive care that is centered on their needs from a team that knows their story
  • Physicians provide appropriate, timely care and establish and continue relationships with their patients and team members
  • Policy makers can see the benefits of a strong, well-supported family practice operating within a robust primary health care system
  • Nurses, nurse practitioners, physiotherapists, pharmacists, and other health professionals work with family physicians to provide PMH patients with the best in care through well-coordinated services and interprofessional collaboration
  • Patients
  • Physicians
  • Policy Makers
  • Other Health Profesisonals

What makes a Patient’s Medical Home

Here are a few of our goals for transforming our family practices:
4. Timely-Access

4. Timely-Access

A Patient’s Medical Home ensures timely access to appointments within the practice, and advocates for and coordinates timely appointments with other health professionals.Better access to care can reduce duplication of services, improve health outcomes, achieve better patient and provider satisfaction, and lead to fewer emergency visits.

3. Team-Based Care

3. Team-Based Care

A Patient’s Medical Home offers its patients an array of services carried out by a team. Collaboration means all team members work together, using their separate and shared expertise, to improve care for patients.

2. Personal Family Physician

2. Personal Family Physician

Every patient should have a family physician. Studies have shown that people with better access to continuing care from their own family doctors have fewer hospitalizations and better health outcomes.

1. Patient Centred-Care

1. Patient Centred-Care

Patient-centred care — meeting the needs of each person and family in the practice — is the core of the PMH vision. Achieving patient-centredness requires the formation of ongoing, trusting relationships between patients, their family physicians, and other health professionals.

10. Internal Supports

10. Internal Supports

Patients’ Medical Homes will be strongly supported internally and externally, through governance and by stakeholders across Canada. The sustainability of Canada’s health care system depends on well-supported primary care and family practice. To achieve their objectives, PMHs will need governments across Canada to support them by showing leadership and providing adequate funding and other resources.

9. Evaluation and CQI

9. Evaluation and CQI

A Patient’s Medical Home will regularly evaluate the effectiveness of its services, as a part of its commitment to continuous quality improvement. Quality not only refers to the effectiveness of a practice’s services, but also to the care that the PMH provides for patients both during and between visits.

7. Electronic Medical Records

7. Electronic Medical Records

A Patient’s Medical Home maintains electronic medical records (eMRs) for its patients. eMRs can enhance the capacity of every practice to provide health care and promote health. Benefits of eMRs include enhanced communicating and information-sharing with patients, better measuring of patient progress, and improved patient adherence to care plans.

8. Education, Training and Research

8. Education, Training and Research

Patient’s Medical Home practices serve as ideal sites for training medical students, family medicine residents, and those in other health professions, as well as for carrying out family practice and primary care research.  The PMH model’s emphasis on research and education is intended to ensure that the knowledge and expertise of family medicine practitioners can be shared with the broader health care community to improve the health care of all Canadians.

6. Continuity of Care

6. Continuity of Care

A Patient’s Medical Home provides continuity of care, relationships, and information for its patients. Continuity of care is defined as consistency of care over time, throughout the course of a patient’s life. Having most medical services provided or coordinated in the same place by one’s personal family physician and team has been shown to result in better health outcomes.

5. Comprehensive Care

5. Comprehensive Care

A Patient’s Medical Home provides its patients with comprehensive scope of services that meet population and public health needs. Studies have shown that a wider range of services provided by primary care practitioners results in better health outcomes at a lower cost. To be most effective, the public health system needs to be linked with a strong primary care network of community-based family physicians and Patients’ Medical Homes.

CanadaAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Practices similar to PMH that exist in Canada

Practices that work on principles similar to the Patient’s Medical Home already exist in several Canadian provinces.

Select province on the map to view details.


Currently, there are 40 Primary Care Networks (PCN) with 3.2 million patients informally enrolled and 800 other health professionals involved.Read More

British Columbia

British Columbia has recently launched “A GP for Me” — a program that pledges to have every British Columbian affiliated with a personal family physician by 2015.Read More


Manitoba saw the development of 4 Primary Care Networks, which are building on the work of Physician Integrated Networks (PINs). Manitoba also promises that every Manitoban will have a personal family physician by 2015.Read More

New Brunswick

In 2011, prototypical Family Health Teams (FHTs) were established and funded by a mix of Health Authority and Department of Health funding.Read More

Newfoundland and Labrador

In 2006 and 2007, Newfoundland and Labrador developed Primary Health Care (PHC) team areas.Read More

Northwest Territories

In addition to growing PMH-like initiatives in Yellowknife, the Northwest Territories have the Integrated Service Delivery Model (ISDM) in health care. These team-based and client-focused practices serve the general population as well as specific patient groups, such as those with diabetes.Read More

Nova Scotia

Nova Scotia has 42 Community Health Centres (CHCs), which are staffed by physicians, nurses, and other health care professionals. Collaborative Emergency Centres (CECs) provide extended hours and access to care.Read More


Currently, Nunavut is working to establish a more robust system of health care providers. Typically, the community health nurse leads an interdisciplinary team and is the first point of contact for patients.Read More


Since 2005, 185 Family Health Teams (FHTs) have been serving over three million Ontarians enrolled in 200 communities.Read More

Prince Edward Island

PEI has five Primary Care Networks, consisting of Health Centres alongside Collaborative Emergency Centres, which provide extended hours and access to care where 24-hour emergency services have been difficult to maintain.Read More


The provincial government stated its intent to revamp Quebec’s health care system by increasing the number of Family Medicine Groups (FMG/GMF) to 300 and to establish super clinics (open to the public 24/7).Read More


Collaborative Emergency Centres (CECs) were established and based on the Nova Scotia model, alongside eight Primary Health Care innovation sites based on community needs.Read More


In Whitehorse, the Diabetes Collaborative exists to manage patients with diabetes and is comprised of family physicians, nurses, physiotherapists, and nutritionists.Read More


Many practices already work on principles similar to the PMH. Assess your practice today to see where you rank and what you could be doing differently.