Patient’s Medical Home
A PMH connects patients to the care and support they need when they need it.
A PMH consists of a family doctor and the multidisciplinary team supporting them. Delivering seamless care centred around patients’ needs – at every stage of life – our team members work directly with doctors and their patients to ensure continuous, effective medical care.
Highlights from 2023-24
Our PMH team provides…
Providing PPIP resources for physicians
In 2023-24, our PCN launched a comprehensive Physician Practice Improvement Program (PPIP) support project. This project’s purpose is to support the doctors in our membership with completing the College of Physicians & Surgeons of Alberta’s (CPSA) three required PPIP activities and reduce confusion relating to the initiative. PPIP activities help doctors to perform their best, resulting in optimized patient care.
Our support included:
- The creation of a dedicated PPIP web page, support guide, action plan examples, and more
- Quarterly PPIP e-newsletters for doctors containing key updates, event details, and resources
- Dedicated events for doctors that helped build knowledge and skills in quality improvement and apply those principles to PPIP activities
- Hosting an engagement event for doctors that highlighted our PCN’s PPIP supports and project examples from their peers
- Facilitated sessions for doctors to reflect on and identify areas of improvement based on their own self-assessment of their progress toward building a medical home for their patients
Across all communication efforts in 2023-24, this support project generated 384 visits to PPIP resources. We also noted an average session duration of approximately five minutes, indicating doctors were actively engaged with the content on the web pages.
Our Health Information Coordinators and Quality Improvement Consultant supported this project by consulting with our members to plan and implement quality improvement projects that would meet PPIP requirements. This support was instrumental in providing information and hands-on project support to the doctors in our membership. Physician Liaisons also worked closely with members to provide resources and education to ease PPIP concerns and help doctors work through their activities.
This project will continue into the next fiscal year, with a continued focus on ensuring all doctors in our membership meet their PPIP requirements and are prepared for potential CPSA audits.
Supporting Alberta Lung Cancer Screening Project referrals
In 2023, Alberta Health Services launched a limited-time Alberta Lung Cancer Screening Program (ALCSP). Our PCN was invited to join the program during its trial phase that allowed all the doctors in our membership to refer eligible patients to the program.
Many PMH team members supported this project:
- Health Information Coordinators and our Quality Improvement Consultant assisted members who wished to begin screening projects for those at risk for lung cancer.
- Primary Care Registered Nurses and Senior Services Registered Nurses assisted at-risk patients with referrals to the ALCSP.
- Nurses also provided smoking cessation support to patients at risk of lung cancer.
By the end of 2023, the program had received 2,686 eligible referrals, 274 of which came from our membership. The importance of this program was felt by our community, with eight referred patients being diagnosed with previously undetected lung cancer.
This program was extended for an additional year, meaning members will continue their referrals for at-risk patients. We are proud to support this program and commend the ALCSP team for the meaningful impact their work has had on our patients.
Assisting doctors with the transition to CII/CPAR
Over the past four years, our Panel Support Program has provided education, support, and guidance relating to joining the Community Information Integration/Central Patient Attachment Registry (CII/CPAR). This provincial program helps bridge the gaps between all providers in a patient’s circle of care, ensuring nothing is missed.
In 2023-24, our Physician Liaisons, Health Information Coordinators (HICs), and our Quality Improvement Consultant (QIC) frequently communicated with our membership to share CII/CPAR updates, timely financial incentives, and available onboarding supports.
To help ease the administrative burden related to onboarding to CII/CPAR, our HICs and QIC supported doctors with a significant portion of the paperwork necessary to complete the change. On average, no more than two hours of time was required by the doctor’s team to join CII/CPAR.
Thanks to the collaboration between doctors in our membership and our teams, over 70 per cent of eligible members are now live on CII/CPAR. We will continue to work with doctors throughout the next year to help them access financial incentives and support them in joining the program.
Celebrating the success of our Mental Health Program
Our Mental Health Program continues to provide exceptional support to patients through psychotherapy appointments, community partner referrals, and self-management resources.
In 2023-24, we created a dedicated web page highlighting the evolution and successes of the program to date. This page is intended to showcase the changes made to the program throughout the last three years that have allowed us to offer accessible mental health care to patients at no cost.
This spring, we expanded the hours of the Mental Health Program to include evenings and weekends — increasing accessibility for patients in need. This included hiring additional Primary Care Registered Psychologists to support expanded appointment times.
We are confident this expansion will provide additional value for doctors in our membership and their patients.
Patient survey: The results are in
Our annual Patient Experience Survey is a valuable tool for evaluating our programs and services. For the 2023-24 fiscal year, the survey was expanded to include patient feedback for our Primary Care Registered Psychologists (PCRPs), Senior Services Registered Nurses, and Social Workers in addition to our Primary Care Registered Nurses.
The 2023 Patient Experience Survey generated 489 unique responses — a record-high response rate for our PCN. This success is due to the hard work of our PMH and Data Management & Evaluation teams.
We were pleased to see overwhelmingly positive results in all areas. These strong results are reflective of the dedication our PMH team members show to patient-centred care.
of patients surveyed rated the care they received from a PCRP as excellent or very good
of patients surveyed rated the care they received from a Social Worker as excellent or very good
of patients surveyed rated the care they received from a Primary Care Registered Nurse as excellent or very good
of patients surveyed rated the care they received from a Registered Nurse with our Senior Services team as excellent or very good
Nurses teaching one another through nursing competencies
Our Primary Care Registered Nurses are consistently enhancing their clinical expertise and conducting research through professional development sessions.
Every month, a different member of the nursing team prepares a presentation for their colleagues on a health issue or chronic condition relevant to their patients. These presentations aim to keep the team informed about recent updates, significant discoveries, and available treatment options pertaining to the chosen subject.
A few of this year’s topics included seniors’ health, mental health, nutrition, respiratory conditions, cardiac conditions, diabetes care, lifestyle management, and weight management.
This effort underscores the commitment of our nursing staff to ongoing learning and delivering exceptional patient care.