In 2011, the CFPC presented the Patient’s Medical Home (PMH) as a vision for the future of family practice in Canada. The goal of this initiative is for every family practice in every community across Canada to be able to offer comprehensive, coordinated, and continuing care to their populations through a family physician working with health care teams.

This vision puts the needs of patients and their communities at the centre of care. The PMH is where patients can present and discuss their personal and family health concerns and receive a full spectrum of expert care. The PMH team is developed to meet the needs of its own patient community. Depending on those needs, teams may involve nurses, other specialists, and other health care providers, who work together in one centre or virtually. The PMH vision also reinforces the physician-patient relationship and the importance of the Four Principles of Family Medicine.

The PMH reflects and responds to the changing needs of Canadians within the context of their own communities. The PMH supports the relationships between patients and family physicians and other health care providers as they develop and strengthen over time, enabling the best possible health outcomes for each person, practice population, and the community being served.

 

Supporting Research Articles

The PMH model is built on a solid foundation of empirical evidence. The summary of research supporting the model’s effectiveness will be released soon.

Download a PDF version of the below reference chart here.

2016

  • Yau I, Kendall C. Socioeconomic status and allied health use: Among patients in an academic family health team. Can Fam Physician. 2016:

    Within an academic FHT, lower-income patients were more likely to use allied health services, suggesting equitable allocation of resources. We encourage other FHTs to similarly assess their allied health resource allocation as an important outcome for investments in Ontario FHTs.

    1. Patient Centred-Care
    5. Comprehensive Care
    9. Evaluation and CQI
  • Andres C, Spenceley S, Cook LL, Wedel R, Gelber T. Improving primary care: Continuity is about relationships. Can Fam Physician. 2016;

    We suggest that the contribution of relational continuity is best captured by measures that give us a sense of how well the primary care provider and team are ensuring that the system wraps around the patient to provide continuous, accessible, person-centred, and comprehensive care. Without these dimensions, any measure of relational continuity is hollow.

    1. Patient Centred-Care
    6. Continuity of Care
    7. Electronic Medical Records
  • Dixon SK, Hoopes AJ, Benkeser D, Grigg A, Grow HM. Characterizing Key Components of a Medical Home Among Rural Adolescents. J Adolesc Health. 2016;

    This sample of rural adolescents reported receiving many characteristics of a medical home but had limited experience with personal providers and confidential services. Improving adolescent access to confidential care may be especially important in small, rural communities. The association of a primary provider with improved medical home experience highlights this key characteristic in an adolescent medical home.

    1. Patient Centred-Care
    2. Personal Family Physician
    4. Timely-Access
  • McHugh M, Shi Y, Ramsay PP, Harvey JB, Casalino LP, Shortell SM, Alexander JA. Patient-Centered Medical Home Adoption: Results from Aligning Forces for Quality. Health Aff (Millwood). 2016;

    We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others.

    5. Comprehensive Care
    9. Evaluation and CQI
    10. Internal & External Supports
  • Slater M, Kiran T. Measuring the patient experience in primary care: Comparing e-mail and waiting room survey delivery in a family health team. Can Fam Physician. 2016;

    Practices should consider evaluating for nonresponse bias and adjusting for patient demographic characteristics when interpreting survey results. Further research is needed to understand how primary care practices can optimize electronic survey delivery methods to survey a representative sample of patients.

    1. Patient Centred-Care
    6. Continuity of Care
    7. Electronic Medical Records
    9. Evaluation and CQI
  • Wong ES, Rosland AM, Fihn SD, Nelson KM. Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden. J Gen Intern Med. 2016;

    Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

    1. Patient Centred-Care
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Applequist J, Miller-Day M, Cronholm PF, Gabbay RA, Bowen DS. “In Principle We Have Agreement, But in Practice It Is a Bit More Difficult”: Obtaining Organizational Buy-In to Patient-Centered Medical Home Transformation. Qual Health Res. 2016;

    Overall, this study suggests that addressing basic communicative principles among practice team members before, during, and after rollout can increase buy-in when done in an effective manner alongside principles of stakeholder theory. Medical practice members must develop better communicative strategies among providers when undergoing the evolution in order to best benefit from its outcomes.

    3. Team-Based Care
    5. Comprehensive Care
    8. Education, Training and Research
  • Cronholm PF, Klusaritz H, Nguyen GT, Kellom K, Kearney M, Miller-Day M, Gabbay R. Resident Engagement in the Patient-Centered Medical Home. Fam Med. 2016;

    The presented data describe the complexities of preparing the next generation of providers for practice. Our mixed-methods study illustrated the strengths of participating in the learning collaborative but also areas of focus necessary for improving the experience and educational benefits of PCMH-related curricula involving residents.

    3. Team-Based Care
    8. Education, Training and Research
    10. Internal & External Supports
  • Miller D, Baumgartner ET. Lessons from the Community-Centered Health Home Demonstration Project: Patient-Centered Medical Homes Can Improve Health Conditions in Their Surrounding Communities. Prev Chronic Dis. 2016;

    All demonstration clinics had an established social mission, and yet the broadening of their focus from individual patient needs to the community’s needs changed their approach to illness and injury prevention.

    3. Team-Based Care
    5. Comprehensive Care
    10. Internal & External Supports
  • Yoon J, Chow A, Rubenstein LV. Impact of Medical Home Implementation Through Evidence-based Quality Improvement on Utilization and Costs. Med Care. 2016;

    After PCMH implementation, overall utilization for primary care, specialty care, and mental health/substance abuse care decreased, whereas utilization for telephone care increased among all practices. Patients also had fewer hospitalizations and lower costs per patient.

    1. Patient Centred-Care
    3. Team-Based Care
    4. Timely-Access
    5. Comprehensive Care

2015

  • Wozniak L, Soprovich A, Rees S, Al sayah F, Majumdar SR, Johnson JA. Contextualizing the Effectiveness of a Collaborative Care Model for Primary Care Patients with Diabetes and Depression (Teamcare): A Qualitative Assessment Using RE-AIM. Can J Diabetes. 2015;

    This study evaluates the implementation of collaborative care model for patients suffering from diabetes and depression. The nurse led team care intervention demonstrated statistically significant improvement in depressive symptoms.

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
  • Hall barber K, Schultz K, Scott A, Pollock E, Kotecha J, Martin D. Teaching Quality Improvement in Graduate Medical Education: An Experiential and Team-Based Approach to the Acquisition of Quality Improvement Competencies. Acad Med. 2015;

    This study evaluates a graduate medical education curriculum to engage family physicians in quality improvement initiatives. The curriculum successfully improved resident compentency to apply quality improvement methods to their practice and research roles.

    1. Patient Centred-Care
    3. Team-Based Care
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Sklar M, Aarons GA, O'connell M, Davidson L, Groessl EJ. Mental Health Recovery in the Patient-Centered Medical Home. Am J Public Health. 2015;105(9):1926-34.

    This study finds that there is a great increase in mental illness recovery, and patient active engagement in treatment in clinics that have embraced the Patient-Centred Medical Home model.

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
    6. Continuity of Care
  • Pineault R, Da silva RB, Provost S, Fournier M, Prud'homme A. [Are new forms of primary health care organization (PHLU) associated with a better health care experience for patients with chronic diseases in Quebec?]. Sante Publique. 2015;27(1 Suppl):S119-28.

    This study demonstrates through patient survey, that individuals with multiple chronic diseases are more likely to have a positive care experience in clinics that use a Patient Medical Home design.

  • Bois C, Michaud C, Pineault R, Guay M. [Retombées des ordonnances collectives dans le suivi diabétique conjoint en soins primaires : une étude de cas]. Santé publique. 2015;27(1 Suppl):S111-8.

    This case study emphasises the benefits of team based care for diabetic patients. Patient's receiving well coordinated team based care are more likely to engage in self-care resulting in increased disease management. (Study in French)

    1. Patient Centred-Care
    3. Team-Based Care
    4. Timely-Access
  • Kaushal R, Edwards A, Kern LM. Association between the patient-centered medical home and healthcare utilization. Am J Manag Care. 2015;21(5):378-86.

    This study demonstrates that the Patient's Medical Home model decreases healthcare costs, as patients use less emergency services and there is a reduction in preventable specialist referrals.

    1. Patient Centred-Care
    9. Evaluation and CQI
  • Wozniak L, Soprovich A, Rees S, Johnson ST, Majumdar SR, Johnson JA. Challenges in Identifying Patients with Type 2 Diabetes for Quality-Improvement Interventions in Primary Care Settings and the Importance of Valid Disease Registries. Can J Diabetes. 2015;

    Patient registries are considered and important foundation of chronic disease management, and diabetes patient registries are associated with better processes and outcomes of care. The purpose of this article is to describe the development and use of registries in the Alberta  Caring for Diabetes (ABCD) project to identify and reach target populations for quality-improvement interventions in the primary care setting.

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
  • Wozniak L, Soprovich A, Rees S, et al. Impact of Organizational Stability on Adoption of Quality-Improvement Interventions for Diabetes in Primary Care Settings. Can J Diabetes. 2015;

    Although there have been tremendous advances in diabetes care, including the development of efficacious interventions, there remain considerable challenges in translating these advances into practice. Four Primary Care Networks (PCNs) in Alberta implemented 2 quality-improvement interventions focused on lifestyle and depression as part of Alberta's Caring for Diabetes (ABCD) project.

    1. Patient Centred-Care
    3. Team-Based Care
    9. Evaluation and CQI
    10. Internal & External Supports

2014

  • Research: Oslin, D. W. A Randomized Clinical Trial of Alcohol Care Management Delivered in Department of Veterans Affairs Primary Care Clinics Versus Specialty Addiction Treatment. Journal of general internal medicine : JGIM, 29, 162. Retrieved June 27, 2014

    Summary of Findings: This randomized clinical trial demonstrates patient centred team-based care has the greatest impact on reducing heavy alcohol consumption in patients suffering from alcohol use disorder. Patients also showed significantly greater levels of treatment compliance and engagement in comparison to outpatient programs with less focus on patient-centred care.

    Download PDF

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
  • Shaw, N. (2014). The role of the professional association: A grounded theory study of electronic medical records usage in Ontario, Canada. International Journal of Information Management, 34(2), 200-209. doi:10.1016/j.ijinfomgt.2013.12.007

    Summary of Findings: This grounded theory study examines physician’s experiences with electronic medical record use through interviews and surveys. Physicians reported significant benefits such as ease of use, improvement to comprehensiveness of care and more efficient use of clinical resources. 

    5. Comprehensive Care
    7. Electronic Medical Records
    8. Education, Training and Research
  • Wetmore, S. (2014). Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic. Canadian Family Physician, 60(4), E230.

    Summary of Findings: This study assesses patient satisfaction with access and continuity of care in an multidiciplinary family medicine clinic. Patients who were less satisfied with care had longer wait times and less continuity with their personal family physician.

    Click to read article

    2. Personal Family Physician
    3. Team-Based Care
    6. Continuity of Care
  • Ivers, N., Barnsley, J., Upshur, R., Tu, K., Shah, B., Grimshaw, J., et al. (2014). "My approach to this job is…one person at a time": Perceived discordance between population-level quality targets and patient-centred care. Canadian Family Physician, 60, 258.

    Summary of Findings: This qualitative study interviews family physicians to determine gaps between quality improvement initiatives and patient centred care. The study recommends a quality improvement framework.

    1. Patient Centred-Care
    5. Comprehensive Care
    9. Evaluation and CQI
  • Rutten, L. F., Vieux, S., Sauver, J. S., Arora, N., Moser, R., Beckjord, E., et al. (2014). Patient perceptions of electronic medical records use and ratings of care quality. Journal of Patient Related Outcome Measures, 2014, 17-23.

    Summary of Findings: This study examines patient perceptions on how electronic medical records relate to quality of care. Patients with a personal family physician using electronic medical records reported higher qualities of care. 

    1. Patient Centred-Care
    7. Electronic Medical Records
    9. Evaluation and CQI
  • Wald, H., George, P., Reis, S., & Taylor, J. (2014). Electronic health record training in undergraduate medical education: bridging theory to practice with curricula for empowering patient- and relationship-centered care in the computerized setting. Academic Medicine, 89, 380-386.

    Summary of Findings: This study discusses the benefits of Electronic Medical Record (EMR) use as part of a physicians undergraduate medical education, exemplified at the Alpert Medical School of Brown University. Graduates of the program are exponetially more confident in intergrating electronic medical records into the patient-physician relationship.

    5. Comprehensive Care
    7. Electronic Medical Records
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Sukalich, S., Elliott, J., Ruffner, G. (2014). Teaching medical error disclosure to residents using patient-centered simulation training. Journal of Academic Medicine , 89, 136-143. 

    Summary of Findings: This study evaluates medical error disclosure to patients as a part of medical training as this is an important part of patient-centred care. Residents with training in medical error disclosure show statistically significant improvements in comprehensive care.

    8. Education, Training and Research
    9. Evaluation and CQI
  • Mautner, D., Pang, H., Brenner, J., Shea, J., Gross, K., Frasso, R. (2013). Generating Hypotheses About Care Needs of High Utilizers: Lessons from Patient Interviews. Population Health Management , 16, S26.

    Summary of Findings: This qualitative study interviews patients that are high utilizers of health services to define which characteristics determine excess use. The findings include lack of access to a personal family physician and healthcare team as indicators of overuse of healthcare services. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
  • Lakbala, P., & Dindarloo, K. (2014). Physicians’ perception and attitude toward electronic medical records. The Journal of Family Medicine, 3, 63.

    Summary of Findings: This cross-sectional survey found that physician’s perceptions of Electronic Medical Records are largely positive. Over 85% of physicians surveyed believe EMR’s should be implemented with the help of government and policy makers to provide incentives. 

    7. Electronic Medical Records
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Muller, S. (2014). Electronic medical records: the way forward for primary care research?. The Journal of Family Practice, 31, 127-129.

    Summary of Findings: This article suggests electronic medical records may also be used as a valuable medical research tool with patient consent. Research suggests this information may be a valuable quality improvement tool for patient-centred care.

    1. Patient Centred-Care
    7. Electronic Medical Records
    8. Education, Training and Research
  • Oswald, A., Czupryn, J., Wiseman, J., & Snell, L. (2014). Patient‐centred education: What do students think? Medical Education, 48(2), 170-180. doi:10.1111/medu.12287

    Summary of Findings: In this study, pre-clinical medical students were asked to submit written assignments on patient-centredness. Most students reported seeing illness in the context of patients lives as a primary component of quality care, emphasising the necessity of patient-centredness as a core aspect of a healthcare system.  

    1. Patient Centred-Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Kamrul, R., Malin, G., & Ramsden, V. (2014). Beauty of patient-centred care within a cultural context. Canadian Family Physician, 60, 313.

    Summary of Findings: This journal article discusses the importance of patient-centred care, primarily in a Canadian culturally diverse context. The researchers encourage a level of cultural competency as a powerful component in comprehensive, patient centred care. 

    1. Patient Centred-Care
    5. Comprehensive Care
    6. Continuity of Care
    8. Education, Training and Research

2013

  • Cook, D., M.D., Rocker, G., D.M., & Heyland, D., M.D. (2013). Enhancing the quality of end-of-life care in canada. Canadian Medical Association.Journal, 185(16), 1383-4. Retrieved from http://search.proquest.com/docview/1476500531?accountid=14771

    Summary of Findings: This study interviews hospitalized Canadians on which aspects of end-of-life treatment they find to be most important. Trust in a personal family physician and effective communication among health care team members were consistantly reported to play a pivitol role in the quality of palliative care. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Green, B. B. (2013). Caring for Patients with Multiple Chronic Conditions: Balancing Evidenced-based and Patient-Centered Care. The Journal of the American Board of Family Medicine , 26, 484-485. 

    Summary of Findings: This study discusses the need for team-based care due to the increasingly high rates of patients suffering from multiple chronic illnesses. Patients with well controlled chronic illnesses are significantly more likely to have access to a health care team, in addition to their personal family physician.

    3. Team-Based Care
    9. Evaluation and CQI
  • Cauch-Dudek, K., Victor, J. C., Sigmond, M., & Shah, B. R. (2013). Disparities in attendance at diabetes self-management education programs after diagnosis in ontario, canada: A cohort study. BMC Public Health, 13, 85. doi: http://dx.doi.org/10.1186/1471-2458-13-85

    Summary of Findings: This study finds that only 1 in 5 patients newly diagnosed with diabetes attend diabetic publicly funded self-management education programs. Emphasising the need for greater comprehensive care, especially in communities with low rates of health program utilization. 

     

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    9. Evaluation and CQI
  • Sibbald, S. L., McPherson, C., & Kothari, A. (2013). Ontario primary care reform and quality improvement activities: An environmental scan. BMC Health Services Research, 13(1), 209. doi: http://dx.doi.org/10.1186/1472-6963-13-209

    Summary of Findings: This study evaluates current quality improvement initiatives in Ontario, Canada and recommends an organized framework to ensure Patient’s Medical Home goals are met. 

    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Daniel, D., Wagner, E., Coleman, K., Schaefer, J., Austin, B., & Abrams, M. (2013). Assessing Progress toward Becoming a Patient‐Centered Medical Home: An Assessment Tool for Practice Transformation. Health Services Research, 48, 1879-1897.

    Summary of Findings: This study provides a Patients Medical Home implementation guide to monitor clinic progress in transitioning to patient-centred care. It highlights the importance of clinic quality improvement to ensure the best possible patient outcomes. 

    1. Patient Centred-Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Hilts, L., Howard, M., Price, D., Risdon, C., Agarwal, G., & Childs, A. (2013). Helping primary care teams emerge through a quality improvement program. Family Practice, 30.

    Summary of Findings: This study measured the relationship between healthcare team perceptions on their care roles and patient health outcomes. Healthcare teams with a better understanding of their role tended to see higher positive patient health outcomes. 

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Siminoff, L. A. (2013). Incorporating patient and family preferences into evidence-based medicine. BMC Medical Informatics and Decision Making, 13, S6. doi: http://dx.doi.org/10.1186/1472-6947-13-S3-S6

    Summary of Findings: This study evaluates the importance of socio-cultural influences of health and it’s relationship to evidence based medicine. The author stresses the importance of patient-centred care and comprehensive care in order to achieve the best health outcomes. 

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
  • Mittelstaedt, T., Mori, M., Lambert, W., Saultz, J. (2013). Provider practice characteristics that promote interpersonal continuity. Journal of the American Board of Family Medicine, 26, 356.

    Summary of Findings: This mixed method study examined the relationship between provider practice characteristics and interpersonal continuity. It determined patients receive greater continuity of care when they have access to nurses and physicians assistants in addition to their own personal family physician. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Giordano, C., Arenson, C., Lyons, K., Collins, L., Umland, E., Smith, K. (2013). Effect of the health mentors program on student attitudes toward team care. Journal of the American Board of Family Medicine , 42, 120.

    Summary of Findings: This study evaluates the effects of a longitudinal study on an education program to train future health professionals skills for efficient team-based care. The program resulted in a significant improvement in attitudes toward team care in addition to a higher quality of care.

    3. Team-Based Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Henschen, B., Garcia, P., Jacobson, B., Ryan, E., Woods, D., Wayne, D, et al. (2013) The Patient Centered Medical Home as Curricular Model: Perceived Impact of the "Education-Centered Medical Home". Journal of general internal medicine : JGIM, 28, 1105-1109.

    Summary of Findings: This study tests the effectiveness of a program called the Education-Centred Medical home, which implements patient-centred care oriented goals into the final years of medical training. Students reported significantly higher levels of confidence in practicing continuity of care and patient centred care. 

    1. Patient Centred-Care
    6. Continuity of Care
    8. Education, Training and Research
  • Fawole, O., Dy, S., Wilson, R., Lau, B., Martinez, K., Apostol, C., et al. (2013). A Systematic Review of Communication Quality Improvement Interventions for Patients with Advanced and Serious Illness. Journal of General Internal Medicine: JGIM, 28, 570.

    Summary of Findings: This study evaluates the impact of various quality improvement methods on physician-patient communication. It finds that patient-centred consultative care is the most effective quality improvement intervention, especially among the chronically ill. 

    1. Patient Centred-Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Sung, N., Markuns, J., Park, K., Kim, K., Lee, H., Lee, J. (2013). Higher quality primary care is associated with good self-rated health status. The Journal of Family Practice , 30, 568-575.

    Summary of Findings: This study determines that there is a high association between quality of primary care and patient reported health outcomes across a majority of demographics. Patients with the most positive health outcomes reported high levels of personalized, comprehensive, coordinated care from their personal family physician. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Kristjansson, E., Hogg, W., Dahrouge, S., Tuna, M., Mayo-Bruinsma, L., & Gebremichael, G. (2013). Predictors of relational continuity in primary care: Patient, provider and practice factors. BMC Family Practice, 14(1), 72. doi: http://dx.doi.org/10.1186/1471-2296-14-72

    Summary of Findings: This cross-sectional study compared a variety of clinics sizes, for example number of physicians practicing, determined that continuity of care is best achieved in clinics with a smaller more cohesive health panel. 

    1. Patient Centred-Care
    3. Team-Based Care
    6. Continuity of Care
  • Haggerty, J., Roberge, D., Freeman, G., & Beaulieu, C. (2013). Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary. Annals of Family Medicine, 11, 262-271.

    Summary of Findings: This qualitative study reviews patient surveys on continuity of care. A majority of patients who experienced continuity of care also had a close relationship with a personal family physician and healthcare team.

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
  • Freeman, T., Brown, J., Reid, G., Stewart, M., Thind, A., & Vingilis, E. (2013). Patients’ perceptions on losing access to FPs: qualitative study. Canadian Family Physician, 59, 195-201. 

    Summary of Findings: This qualitative study interviews individuals on their health-related experiences after losing their personal family physician. A majority of participants reported distress, as they no longer had consistent access to preventative care. The quality of chronic illness management also decreased significantly. 

    1. Patient Centred-Care
    2. Personal Family Physician
    4. Timely-Access
    6. Continuity of Care
    10. Internal & External Supports
  • Hudon, C., Tribble, D. S., Bravo, G., Hogg, W., Lambert, M., & Poitras, M., et al. (2013). Family physician enabling attitudes: a qualitative study of patient perceptions. BMC Family Practice, 14. 

    Summary of Findings: This descriptive qualitative study of patients with at least one chronic illness finds that a positive relationship with their personal family physician was one of the most crucial components to their quality of care. Patients report that physician understanding of their specific illness experience is directly related to health outcomes. 

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
    6. Continuity of Care
  • Brown, A. E., & Pavlik, V. N. (2013). Patient Centred Research Happens in Practice-Based Research Networks. Journal of the American Board of Family Medicine, 26, 481-483.

    Summary of Findings: This article discusses the benefits of conduting medical research in a clinic setting in order to obtain the best patient-centred results. Research suggests that policy makers invest in patient-centred research in these settings for outcomes that can be applied to actual medical practice. 

    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Michael, M., Schaffer, S., Egan, P., Little, B., & Pritchard, P. (2013). Improving Wait Times and Patient Satisfaction in Primary Care. Journal for Healthcare Quality , 35, 50-60.

    Summary of Findings: This study compares two frameworks designed to improve patient satisfaction by minimizing wait times. Both were able to reduce wait times by 10 minutes, leaving room for further research and quality improvement to build on these frameworks to increase quality of care. 

    1. Patient Centred-Care
    4. Timely-Access
    9. Evaluation and CQI

2012

  • Aarts, J. W. M., Huppelschoten, A. G., van Empel, I. W. H., Boivin, J., Verhaak, C. M., Kremer, J. A. M., & Nelen, W. L. (2012). How patient-centred care relates to patients’ quality of life and distress: A study in 427 women experiencing infertility. Human Reproduction, 27(2), 488-495. doi:10.1093/humrep/der386

    Summary of Findings: This study uses a cross-sectional questionnaire determines patient centredness in family planning and fertility care strongly relates to patient quality of life. Specifically, participants that received quality patient centred care experienced far fewer instances of anxiety and depression than participants who did not receive the same care. 

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Lisa Kern et al., "Electronic Health Records and Ambulatory Quality of Care," Journal of General Internal Medicine, Oct. 3, 2012

    Summary of Findings: This study determines that physicians that utilize electronic medical records (EMR) provide significantly higher quality of care compared to practices that are not using EMR’s. Specifically, patients experienced a higher quality of care in diabetes management, clamydia screening and cancer screening.

    5. Comprehensive Care
    7. Electronic Medical Records
  • Specialized community-based care: an evidence based analysis. Ontario health technology assessment series, 13. (2012)

    Summary of Findings: This qualitative study examines how patients with chronic diseases, such as corinary artery disease, are able to self manage their illness. The patients studied who had a longitudinal relationship with their personal family physician and had access to a healthcare team had better control of their illness. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
  • MacCarthy, D., Kallstrom, L., Kadlec, H., & Hollander, M. (2012). Improving primary care in british columbia, canada: Evaluation of a peer-to-peer continuing education program for family physicians. BMC Medical Education, 12, 110. doi: http://dx.doi.org/10.1186/1472-6920-12-110

    Summary of Findings: This study determines a Practice Support Program (PSP) in British Columbia, Canada is an effective way to improve physician office efficiency, strategize wait time reduction methods. Additionally, after participating the PSP program, over 82% participants felt more comfortable diagnosing and treating mental health conditions.

    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Specialized community-based care: an evidence-based analysis. (2012). Ontario health technology assessment series, 12, 1.

    Summary of Findings: This study reviews the effects of comprehensive community care on diabetes, heart disease, and chronic obsturctive pulmonary disease. Populations that receive comprehensive community care are significantly less likely to require emergency services and self report greater quality of life than those who do not have these services.  

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    9. Evaluation and CQI
  • Alexander, J. A., Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient–Physician Role Relationships and Patient Activation among Individuals with Chronic Illness. Health Services Research, 47, 1201.

    Summary of Findings: This cross-sectional study finds that the physician-patient relationship is strongly coorrelated to patient engagement. Patients with strong longitudinal relationships with their personal family physicians are more likely to adhere to treatment plans and experience better health outcomes.

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
    6. Continuity of Care
  • Bryant, S., Lande, G., & Moshavi, D. (2012). A Knowledge-based view of improving the physician-patient relationship. Academy of Health Care Management Journal, 8(1), 9-19. Retrieved from http://search.proquest.com/docview/1037802664?accountid=14771

    Summary of Findings: This qualitative study uses hypertension to describe the importance of increased information sharing between patients and physicians. The research stresses physicans to gain a better understanding of patient lifestyles and cultures that may influence comprehensive care.

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
  • Randall, E., Crooks, V., Goldsmith, L. (2012). In search of attachment: a qualitative study of chronically ill women transitioning between family physicians in rural Ontario, Canada. BMC Family Practice, 13, 125.

    Summary of Findings: This qualitative study interviews women in rural Ontario, Canada with chronic illnesses on continuity of care and stresses the necessity of personal family physicians. There is a shortage in physicians practicing in rural areas, which causes patients to frequently transition through personal family physicians, limiting their continuity of patient-centred care and worsening their health outcomes. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    4. Timely-Access
    6. Continuity of Care
  • Klemenc-Ketis, Z., Vanden Bussche, P., Rochfort, A., Emaus, C., Eriksson, T., & Kersnik, J. (2012). Teaching quality improvement in family medicine. Education For Primary Care, 23(6), 378-381.

    Summary of Findings: This research report discusses the importance of teaching quality improvement measures throughout medical education. System performance, professional development and patient outcomes significantly benefit from consistant quality improvement systems so that policy makers can make informed decisions on the best practices for patient-centred care.

    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports
  • Sternlieb, J. (2012). Teaching the value of continuity of care: a case conference on long-term healing relationships. Family, Systems & Health: The Journal of Collaborative Family Healthcare, 30, 302-307.

    Summary of Findings: This study discusses the importance of continuity of care as part of medical training. Physicians that prioritize continuity of care are far more likely to provide a high quality of comprehensive patient centred care. Their patients are also more likely to have better control over chronic illnesses.

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    9. Evaluation and CQI
  • Nasser, M., van Weel, C., van Binsbergen, J., & van de Laar, F. (2012). Generalizability of systematic reviews of the effectiveness of health care interventions to primary health care: concepts, methods and future research. The Journal of Family Practice , 29, i94-i103.

    Summary of Findings: This study systematically reviewed a variety of primary care guidelines, such as patient-centred care and continuity of care and determined these goals improved quality of care and patient in among a majority of patient demographics. The researchers additionally note the importance of team-based care, especially in communities of lower socio-econimic status. 

    1. Patient Centred-Care
    6. Continuity of Care
    9. Evaluation and CQI
  • Uijen, A., Schers, H., Schellevis, F., & van den Bosch, W. (2012). How unique is continuity of care? A review of continuity and related concepts. The Journal of Family Practice , 29, 264-271.

    Summary of Findings: This study examines the universality of the realtionship between the patient and their personal family physician, communication between healthcare professionals. Researchers recommend health policy makers prioritize these aspects of the Patient’s Medical Home as it has proven to be instrumental to high quality care.

     

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
  • Lawrence, M., & Kinn, S. (2012). Defining and measuring patient-centred care: an example from a mixed-methods systematic review of the stroke literature. The Journal of Health Expectations, 15, 295-326.

    Summary of Findings: This study uses stroke patients as a way to demonstrate the importance of patient-centred interventions. The research finds that patient relevance, communication and quality of care are essential components of patient centred care and must be considered when developing treatment plans.

    2. Personal Family Physician
    5. Comprehensive Care

2010

  • Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a relationship centered approach. Ann Fam Med. 2010;8(Suppl 1):S68-S79.

    Summary of Findings: Building on existing research on primary care practices, this study further demonstrated the determinants of successful practice development such as comprehensive care and continuity of care. Prioritizing these aspects of the patients medical home dramatically increased chronic disease prevention and treatment.

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    6. Continuity of Care
  • Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff. 2010;29(7):1370-1375.

    Summary of Findings: Implementing secure patient to physican e-mail as part of their EMR system, the clinic saw a statistically significant improvement in the overall health of diabetic patients. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    7. Electronic Medical Records
    8. Education, Training and Research
  • Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF. Principles of the patient-centered medical home and preventive services delivery. Ann Fam Med. 2010;8(2):108-116.

    Summary of Findings: This study assessed clinics utilizing the principles of the Patient’s Medical Home, such as a personal family physician, were far more likely to receive preventative services.

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    4. Timely-Access
    5. Comprehensive Care
    6. Continuity of Care

2009

  • Walker J, Harris/Decima. Poll: Nine in ten Canadians have a family doctor. 2009. Available at: http://www.harrisdecima.ca/sites/default/files/releases/061909E.pdf. Accessed August 18, 2011.

    Summary of Findings: Almost 90% of Canadians have a personal family doctor. Of those Canadians, 88% rate the care they receive as excellent or good. 

    2. Personal Family Physician
    9. Evaluation and CQI
  • Atlas SJ, Grant RW, Ferris TG, Chang Y, Barry MJ. Patient–Physician connectedness and quality of primary care. Ann Intern Med. 2009;150(5):325-335.

    Summary of Findings: This study demonstrates a strong correlation between a patient’s adherance to treatment and a good relationship with their personal family physician.  

    1. Patient Centred-Care
    2. Personal Family Physician
    5. Comprehensive Care
  • Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Managed Care. 2009;15(9):e71-e87.

    Summary of Findings: This study surveyed clinics practicing a patient-centred medical home system and found that patients achieve better outcomes at a lower cost compared to clinics not using the PCMH model. 

    1. Patient Centred-Care
    3. Team-Based Care
    4. Timely-Access
    7. Electronic Medical Records
    9. Evaluation and CQI

2008

  • Khan S, McIntosh C, Sanmartin C, Watson D, Leeb K. Primary Health Care Teams and Their Impact on Processes and Outcomes of Care. Ottawa, ON: Statistics Canada; 2008. Available at:  http://www.statcan.gc.ca/pub/82-622-x/82-622-x2008002-eng.pdf.

    Summary of Findings: According to this recent survey, Canadians who have regular access to team based care are significantly less likely to require emergency medical services than those who are not connected to a healthcare team. 

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    5. Comprehensive Care
  • Haggerty JL, Pineault R, Beaulieu M-D, et al. Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care. Ann Fam Med. 2008;6(2):116-123.

    Summary of Findings: This study compares the relationship between patient-centred care and the sustainability of the Canadian healthcare system. It emphasizes the increased demand for primary care as the population ages, and recommends a shift to patient-centred care in order to sustain the healthcare system and better health outcomes.

    1. Patient Centred-Care
    2. Personal Family Physician
    4. Timely-Access
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI
    10. Internal & External Supports
  • Clatney L, MacDonald H, Shah SM. Mental health care in the primary care setting: family physicians’ perspectives. Can Fam Physician. 2008;54(6):884-889.

    Summary of Findings: This survey reveals that primary practicioners are unsatisfied with the quality of mental health care they are able to provide for their patients due to barriers in accessing mental health specialists urging the need for increased team-based care.

    1. Patient Centred-Care
    3. Team-Based Care
    4. Timely-Access
    5. Comprehensive Care
    6. Continuity of Care
    9. Evaluation and CQI

2007

  • Soklaridis S, Oandasan I, Kimpton S. Family health teams: can health professionals learn to work together? Canadian Family Physician. 2007;53(7):1198-1199.

    Summary of Findings: This study finds the need for more effective opportunities in academic primary care settings for future primary physicians are able to practice teamwork and collaboration with other health professionals.

    1. Patient Centred-Care
    3. Team-Based Care
    5. Comprehensive Care
    8. Education, Training and Research
    9. Evaluation and CQI
    10. Internal & External Supports

2005

  • Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician.  2005;72(8):1503–1510.

    Summary of Findings: Chronic disease patients who participated in this study that had access to a cohesive health care team were able to better self- manage their illness leading to a higher satisfaction with their care.

    1. Patient Centred-Care
    2. Personal Family Physician
    6. Continuity of Care
    7. Electronic Medical Records

2000

  • Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manage. 2000;7(8):45.

    Summary of Findings: Three different primary care appointment booking models are compared. Clinics that have embraced the advanced same-day care model were able to reduce appointment wait times from 55 days to 1 day.

    1. Patient Centred-Care
    2. Personal Family Physician
    3. Team-Based Care
    4. Timely-Access
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