top-medical-homeThe College of Family Physicians of Canada (CFPC) defines the Patient’s Medical Home (PMH) as a central hub where patients feel most comfortable in discussing their healthcare needs. It is where a team of healthcare providers work together with the patient’s family physician to provide and coordinate a comprehensive range of medical and healthcare services. AIM is dedicated to supporting PCNs and their clinics in building the patient’s medical home.

This includes the implementation of key change concepts focused around:

Engaged Leadership

Engaged leaders are key to influencing a culture of change by ensuring team members have the time and resources to build the key aspects of the medical home. There are essential roles for leaders to play in the change process, such as encouraging specific strategies to improve quality and spread and sustain change. Ways in which AIM engages leaders in PMH planning include:

  • Identifying key conditions within the health system that require spread and scale of local innovation.
  • Working with PCN leaders to co-create a spread strategy that will include staff training, communication approaches and member practice engagement tactics, among others.

Capacity for Improvement

The role of healthcare practitioners is evolving from being providers of healthcare to a mindset of dual responsibility that includes delivering care, while improving how it’s delivered. Capacity for improvement involves the use of quality improvement (QI) models and health information technology to establish and monitor metrics to assess improvement efforts and outcomes. This element of the PMH is one in which AIM excels. Building a capable, adaptable workforce in primary care is a foundational philosophy of the AIM program. The training programs available for improvement facilitators, senior consultants and physician champions are a key part of AIM’s contribution to building medical homes.

Whether teams are doing enhanced access work in practices for your PCN, championing change as a PCN leader or seeking to become an expert resource in the field of QI, AIM has something for you. AIM builds transferrable skills and hosts advanced QI training opportunities through mentorship support on delivering priority QI projects in your organization. The idea is for teams to take their QI learnings from the workshop back to the workplace.

Panel & Continuity

The third pillar of a PMH is Panel & Continuity. As physicians know, the patient and the patient panel are the essence of the medical home because this is where relationships are established. Once those relationships are formed, physicians and care teams can treat and educate patients to ensure the best possible health outcomes. The AIM team works collaboratively with physicians to ensure their panels are the right size for them and their care teams, by exploring some of the following questions:

  • Are you considering accepting new patients, or closing your panel to new patients?
  • Do you understand the health and wellness needs of your patients?
  • What proportion of the time do your patients visit other providers/practices to seek care? Why might they do this? Where do they go? For what reasons?
  • Have you considered how many times per year they see you? When should they come back to see you?

Data is available in the form of panel reports for the Health Quality Council of Alberta as well as Alberta Health to help you make the best decisions for your practice.

To meet the advancing needs of panel management and ensure high continuity, AIM works collaboratively with Toward Optimized Practice (TOP). Together we strive to support the evolving needs of clinics and providers on panel maintenance and management approaches.

Team Based Care

The right provider, for the right patient, at the right time. One of the main objectives of team based care is to ensure patients are able to see their providers as quickly as possible. This is also one of the key principles of the AIM program. AIM can ‘Optimize your Supply’ by using the extended care team in practice, or PCN team to full scope, resulting in many benefits for physicians, the team and patients. Based on each individual panel of patients, AIM will work with physicians to strategize how their care teams can be used to reduce delays for, and at, appointments.

Affecting change also requires a well-functioning clinic team. AIM’s team development and effectiveness training programs determine where teams are at, followed by the co-creation of a plan to optimize team functioning.

Visit our Team Effectiveness workshops for a complete list of our current offerings.

Organized Evidence Based Care

Organized Evidence Based Care means that healthcare teams are ensuring that every patient interaction is designed to meet a patient’s preventive and chronic illness needs, using planned interactions and ensuring appropriate follow-up care. Effective, efficient chronic care planning and chronic disease management are important to the AIM team. AIM works collaboratively with healthcare partners in the AMA and AHS to support proactive care provision for all complex, high-needs patients. One of the partnerships that AIM is proud to support is the Primary Health Care Resource Centre, which is a central hub of information for healthcare providers who can access resources, research and educational opportunities.

AIM also specializes in collection of data to help understand the current state of your ‘system.’ Choosing what to measure is instrumental to understanding if any changes you want to make result in an improvement. Taking a pragmatic approach to measurement is essential to supporting organized, evidence based care.

Visit our Organized Evidence Based Care (Measurement) workshops for a complete list of our current offerings, and the Measurement resources for for a complete list of relevant evidence based research.

Patient Centred Interactions

Patient Centred Interactions are about including patients as active participants in mapping out solutions that meet their healthcare needs. It’s also about respecting patients and valuing their input. AIM consultants are highly skilled in assisting healthcare providers with understanding how small behavioural changes can have tremendous results.  This is accomplished through HealthChange® Methodology, a program that provides person-centred care and promotes health literacy, shared decision making, behaviour change and self-management to support adherence to evidence-based recommendations for improved health and quality of life.

The AIM team also regularly consults with patient engagement specialists in order to provide useful resources for:

  • Providers/teams looking to engage patients in their practice design processes or improvement efforts.
  • Patient representatives who are looking to be good advocates for patients and supportive change agents when working with healthcare improvement teams.

Visit our Patient Centred Interactions workshops for a complete list of our current offerings.

Enhanced Access

Enhanced Access to care is an essential step in building the medical home. The results of enhanced access include improved patient outcomes, improved patient experience and reduced healthcare costs. Working towards enhanced access isn’t just about having facilities accessible 24 hours a day, but rather looking closer at the way care is organized and delivered. This domain is the core of AIM’s work, and we help physicians and their teams think about the following possibilities:

  • What could be accomplished in a practice with better access?
  • How could an improved process for patient follow-up after discharge from hospital affect your patient and your team?
  • How would relationships be strengthened if patients could get in without waiting?
  • What efficiencies could be created?
  • Would you like to be able to conduct outreach screening maneuvers and pull tomorrow’s work into today but haven’t figured out how to make that happen in your busy schedule?

AIM offers workshops, PCN embedded collaboratives and consultative approaches to support improvements in access for patients to their primary care teams. Our workshops focus on topics like High Leverage Change options that will guide teams in understanding their panels to ensure optimal patient experiences and staff satisfaction. We also challenge teams to consider how the potential for system change can improve patient care and work with them to effectively implement these changes.

Visit our Enhanced Access workshops for a complete list of our current offerings.

Care Coordination

Care coordination is the final piece in the implementation of the Patient’s Medical Home. At this level, the primary care practice is the hub, where the patient receives seamless care and connection to specialists, labs, hospitals and other community resources. In Alberta, supporting care coordination and enhancing transitions in care is a health system priority. AIM has established key partnerships within AHS and PCNs to ensure access to and transitions between specialist services and community resources are available. Such collaborations are being designed so that all partners in healthcare are coming together to achieve a common objective of care coordination. Key collaborations that AIM is involved in include:

One of the specific roles for AIM in this implementation element of the PMH is in developing a specialty care curriculum focused on supporting coordinated care between primary and specialist services. We will be providing additional details on this program as development concludes and the curriculum becomes available to providers.