Patient's Medical Home
The AMA uses the following definition and framework for the Patient’s Medical Home. It is based on the definition developed by the College of Family Physicians of Canada.
Definition
The Patient’s Medical Home (PMH) is a family practice defined by its patients as the place they feel most comfortable to discuss their personal and family health concerns. The goal is to have the patient’s family physician, the most responsible provider of their medical care, work collaboratively with a team of health professionals, which may include nurses, pharmacists, nutritionists and others as required, to coordinate comprehensive healthcare services and ensure continuity of patient care. These professionals can be located in the same physical site as the family physician or linked through different practice sites, telehealth or other enabling communications. The PMH enables the best possible outcomes for each person, the practice population and the community being served.
Tools and Resources
Creating a Patient’s Medical Home may mean changing some of the ways in which you practice. It can mean adding new team members, optimizing your EMR, adding virtual care enablers and more. Resources to start and supports to continue can be found on the Accelerating Change Transformation Team (ACTT) website. ACTT is an Alberta Health grant-funded program operated by the AMA, that finds, curates, and builds materials for change. Its role includes creating capacity enablers, supporting partners, and influencing policy, practice, funding, and services to maximize the chances of successful transformative change.
Implementation Elements
Engaged Leadership
- charts the course
- provides resources and tools to support transformation
- removes barriers
Capacity for Improvement
- committed to evidence-based medicine
- responsive to patient feedback
Panel & Continuity
- physicians and teams know whose care they’re responsible for
- patients see the same provider and care team whenever possible
Team-based Care
- Supporting physical and mental health needs
- prevention and wellness
- acute and chronic care
Organized Evidence-Based Care
- meets patients’ needs - preventive, acute and chronic illness
- embeds evidence-based guidelines into daily practice
Patient Centred Interactions
- Care that focuses on the whole person
- Patients and families are partners in care
Enhanced Access
- when the patient wants or needs it
Care Coordination
- Patient’s medical home is the centre of patient/family care
- aligns care between specialists, hospital, community services, and others
