Kootenay Boundary Division of Family Practice

Patient Medical Home & Primary Care Network

British Columbia has started to adapt the Patient Medical Home (PMH) model of primary care delivery.Right Care, Right Place

A PMH is a family practice defined as the place patients feel most comfortable to discuss their personal and health concerns. The Most Responsible Provider – a family doctor or nurse practitioner – works collaboratively with a team of health professionals, either within or linked with the practice, to deliver longitudinal, comprehensive and co-ordinated care of patients.

In BC, the patient medical home is now being recognized as the foundation on which to build a streamlined and accessible service to patients. The following website provides more detail on the plan for patient medical homes in BC:

http://www.gpscbc.ca/what-we-do/primary-care-bc/patient-medical-home

At the community level, individual PMHs are networked with each other and optimally integrated with health authority and community services, to form a Primary Care Network (PCN).

The PMH/PCN model is currently being piloted in several Proof of Concept projects throughout BC. Collaborative work between the KB Division of Family Practice, Interior Health and the Boundary region medical staff, led to the Rural Proof of Concept of Primary Care Network in theRight Care, Right Place Grand Forks/Kettle Valley Geographic Service Area.

The Boundary PMH/PCH Proof of Concept Model builds on high-skill, rural generalism, for staff and services. In rural communities, where economies of scale for specialized services are absent, highly skilled and highly integrated teams are an effective approach to affect the core system challenges of attachment/access, Emergency Department visits, Alternate Level of Care days, Ambulatory Care Sensitive Condition admissions, Mental Health Substance Use and Frail Senior care.

This model focuses on the Primary Care Network (enhancing patient medical homes and integration with existing health authority and community services) and does not include development of specialized community service programs.

Primary Care Network

In late spring 2018, Kootenay Boundary was chosen as one of 10 BC regions to first design its Primary Care Network (PCN). Since then, KB Division, together with its Interior Health and Ministry of Health partners, has been busily working on a PCN service plan that was submitted on October 1st, 2018.

The MoH’s primary goal for the PCN roll-out is to close the attachment gap (est. 15,125 in KB),BDH Changes the secondary goal is to redesign the delivery of primary care, including team-based care and better alignment/integration of Interior Health services (e.g. mental health, home health).

The Division would like to thank all members who have taken part in the many meetings and community engagements that have been held over the past three years to gain insight into clinic and community needs for the Patient Medical Home / Primary Care Network. This feedback has shaped the PCN service plan we have developed.

The KB PCN service plan proposes a mix of new resources, including GPs, NPs, social workers, primary care nurses, physiotherapist and occupational therapists who are anticipated to work within primary care homes. In addition, the plan proposes some regional support staff (clinical pharmacist, virtual care & indigenous health coordinator and change management supports (coaches, EMR specialist).

It is anticipated to know the result of this application process by the end of November and the roll-out to start in January 2019.

If you're interested in learning more about the PMH/PCN work happening in Kootenay Boundary, please contact Julius - juliushw@divisionsbc.ca