Surrey-North Delta Division of Family Practice

Patient Medical Home (PMH)

"The Patient Medical Home is a family practice defined as the place patients feel most comfortable to discuss their personal and health concerns. The Surrey-North Delta Division of Family Practice is working with physicians to develop and strengthen strong patient medical homes throughout the community. From helping patients find a local family doctor where they feel comfortable, to building and empowering the team working in the family practice, to focusing on specific vulnerable patients that need extra help accessing health care, the division is listening and responding to the community's needs and specific context. 

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Surrey-North Delta 2025: Integrated Primary and Community Care for Diabetes and Mental Health

Coming Together

April 14th saw over 90 stakeholders from across Surrey and North Delta gather to discuss improving primary and community care for diabetes and mental health.  Patient partners, local community organizations, Fraser Health partners, Nurse Practitioners and Family Physicians came together early on a Sunday morning for an opportunity to dialogue and to collaborate with each other. 

A large group mind-mapping activity was an exciting opportunity for participants to share their observations, and identify trends influencing mental health and diabetes.  Over the day, participants agreed that these two separate health conditions are intertwined; there are many cultural trends that are impacting the delivery of care and the high incidence of these two health conditions in our community, and mental health and diabetes need to be considered in tandem as we develop best models of care.

As the focus of the day shifted from the present to the future, each of the fourteen table groups wowed the room with their presentations of desired future scenarios.  Highlights from the presentations included poems, musical renditions, dramatic scenes, an imaginary visit from BC’s Future Cabinet Ministers, and media reporters showcasing patient- and care provider-centered family practices and health systems in 2025.  Participants identified theme areas from these future scenarios, and in the final activity of the day worked in breakout sessions on the theme area they felt strongly about in order to identify next steps.

**A summary of the themes is included below.

Impact of the Event

Participants appreciated the discussions and collaboration with a large group of diverse community stakeholders, and the opportunity to share their thoughts and experiences.  Even at five hours, the time seemed too short for the topic and the tremendous energy in the room.  Participants indicated they would like more of these collaborative meetings, and want to follow-up on the ideas generated on April 14th to move towards concrete action for integrating primary and community care.

Click here, APRIL 14th EVENT SUMMARY

Our Next Steps Together

The themes that emerged will be matched to see where they might inform work that is currently going on in Surrey-North Delta; and themes that do not currently have a focus will be referred for prioritization by the Primary Care Network Working Group, a collaborative group of family physicians and Fraser Health employees working in Surrey-North Delta, who are currently meeting biweekly to discuss and move forward the integration of primary and community care.

At the same time, neighbourhood-focused groups of family physicians and partners will be invited to begin meeting regularly to discuss their more immediate and local needs, and to identify the supports they would like to see to achieve a more integrated system.

Join Us!

If you would like more information about integrated community care, need assistance connecting with one of the participants at the event, or would like to become more involved in one or more of the theme areas that emerged, do not hesitate to reach out to our division staff, who will be able to provide you with information about available opportunities.

**Key Themes:

  1. Collaboration and Team-Based Care - To address complex health care needs, family physicians, Fraser Health, community organizations and patients will achieve greater outcomes through collaboration.  There is an appetite to address current gaps by deploying allied health services within or close to family practices and investing in team-based care.
  2. Prevention and Public Education - Patient education and awareness are integral to the success of any health care system.  There is a need to shift our focus from “treating the illness” to “preventing the illness”.
  3. Health Education in Schools - Health promotion and education about diabetes and mental health for school-aged children and youth is an integral part of implementing a best model of care.
  4. Compassion and Trauma-Informed - Advocate for, identify with, understand and work toward: empathy, compassion and kindness, embodied in all levels of connection.  From cultural empathy to the practices and treatments provided, the goal is patient wellness.
  5. Physician Wellness – Health care providers are able to provide excellent, quality health care when there is also a focus on their own wellness.
  6. Easy Access – Prioritize timely access to mental health services, as well as an ongoing dialogue with primary care providers and community partners involved with mental health care and wellness.
  7. Electronic Medical Records – Interoperability between care providers’ medical records will support an integrated primary and community care system.
  8. Funding - Health care treatments and disease prevention services must be financed to incentivize coordinated care with acceptable access.

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In case you missed our earlier session, Redesigning Primary Care: Your Vision on January 27 and Our Invitation for Action, click here, EVENT SUMMARY

Where can I learn more? To learn more about the Patient Medical Home and Primary Care Network development in Surrey-North Delta contact Tomas Reyes at or 778-302-9220. To learn more about the Patient Medical Home, and the work that is going on across the province in alignment with this model, click here

How can I become involved?

To learn more about the Patient Medical Home, and the work that is going on across the province in alignment with this model, click here