Team-Based Care
COMPREHENSIVE TEAM-BASED CARE WITH FAMILY PHYSICIAN LEADERSHIP
A broad range of services is offered by an interprofessional team. The patient does not always see their family physician but interactions with all team members are communicated efficiently within a PMH. The team might not be co-located but the patient is always seen by a professional with relevant skills who can connect with a physician (ideally the patient’s own personal physician) as necessary.
RECOMMENDATION #1
A PMH includes one or more family physicians, who are the most responsible provider for their own panel of registered patients.
RECOMMENDATION #2
Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or network, collaborating with the patient’s personal family physician to provide timely access to a broad range of primary care and consulting services.
RECOMMENDATION #3
On-site, shared-care models to support timely medical consultations and continuity of care are encouraged and supported as part of each PMH.
RECOMMENDATION #4
The location and composition of a PMH’s team is flexible, based on community needs and realities; team members may be co-located or may function as part of virtual networks.
RECOMMENDATION #5
The personal family physician and nurse with relevant qualifications form the core of PMHteams, with the roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers, physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed.
RECOMMENDATION #6
Physicians, nurses, and other members of the PMH team are encouraged and supported indeveloping ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal medical home team.
RECOMMENDATION #7
Nurses and other health professionals in a PMH team will provide services within their defined roles, professional scopes of practice, and personally acquired competencies. Their roles providing both episodic and ongoing care support and complement—but do not replace—those of the family physician.
Evidence
There is evidence from across Canada that the PMH model is making a difference. Visit our Evidence page to see it for yourself!
Choose Another Pillar
Improvement & Research
Professional Development
Accessible Care
Partnered Care
Continuity of Care
Accountability
Infrastructure
Connected Care
Administration
Tool Kit
Ready to implement the PMH Vision into your practice? Start here by downloading the starter tool kit.
