President's Message

Paul Sawchcuk, MD, MBA, CCFP, FCFP

The CFPC’s updated Patient’s Medical Home vision outlines how to improve access to comprehensive team-based care

As I write this I am looking at the soon-to-be-released refreshed version of the Patient’s Medical Home (PMH), the CFPC’s vision for family practice in Canada. The PMH is a great contribution to our health care system. I want to acknowledge the hard work of colleagues who have volunteered their time as a part of the PMH Steering Committee.

I am a fan of all the pillars of the PMH, but the one I will highlight here is comprehensive team-based care with family physician leadership. When I started my career 25 years ago I worked in Bella Bella, British Columbia. Our idea of a multidisciplinary team back then was having a nurse work in our clinic to help with triage, dressing changes, immunizations, and blood pressures. Now I work in a primary clinic in Winnipeg where the interprofessional team is much more robust.

Since our clinic opened in 2004 we have always had nurses, nurse practitioners, a mental health counsellor, and a dietitian. Now our community of about 120,000 people has access to My Health Teams, a relatively new collection of health care providers who take referrals from all participating family physicians in the area. Our My Health Team consists of a chronic disease clinician (nurse), a respiratory therapist, a chronic pain/mental health clinician (occupational therapist), a mental health/addictions clinician (occupational therapist), and a social worker. I often say, “I used to prescribe medications for diabetes/COPD/chronic pain/depression/etc.; now I prescribe colleagues.” Many of my patients have benefited from interactions with members of the interprofessional team; these relationships we build are what make the difference in providing patient-centred care compared with medications alone.

Of course, access to extensive interprofessional teams is uneven in Canada. There is value in the Manitoba model, which does not confine the team to a single clinic but offers the service to a wider community. There are similar models in other jurisdictions, such as Primary Care Networks in Alberta and Family Health Teams in Ontario. While these government-supported strategies help clinics apply the principles of the PMH, an important new feature of PMH 2019 is a list of recommendations that practices of all kinds can apply to benefit from the vision we have developed.

We have a long way to go before comprehensive team-based care is available to everyone in Canada, but with the blueprint provided by PMH 2019—and governments across Canada taking note—we are moving in the right direction.

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