Patient’s Medical Home
A Patient’s Medical Home (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 2024-25
Our PMH team provides…
Expanding hours for Mental Health Program appointments
Our Mental Health Program is a highly utilized resource that provides self-management resources, community resource connections, and psychotherapy appointments to those who need them.
In 2024, we began offering evening and weekend appointment options (4:30 – 9 p.m. on weekdays and 8:30 a.m. – 4:30 p.m. on weekends) with our Primary Care Registered Psychologists (PCRPs). These expanded appointment options increased accessibility for our patients, ensuring no one is missed.
This program expansion has been very successful, with more than 369 evening and weekend appointments offered in 2024.
This expansion highlights our commitment to the continuous improvement of our programs and services to meet the needs of our community. You can learn more about our Mental Health Program on its dedicated web page.
In our annual Patient Experience Survey:
of respondents with an evening or weekend appointment agreed or strongly agreed that these options allowed them to access services to which they would otherwise not be able to access
Launch of a new Screening and Prevention Program
Screenings for conditions like diabetes, heart health, bone density, and more can help catch chronic diseases early. Our PCN offers doctors in our membership the support of a Health Information Coordinator (HIC) and Patient Care Coordinator (PCC) to help evaluate panel data and implement relevant screening projects.
This last fiscal year, we launched a new Screening and Prevention Program (SaPP) to help streamline the way we support our members’ screening projects. The SaPP uses provincial guides — like the Alberta Screening and Prevention (ASaP) guidelines — to determine which projects will benefit the largest group of patients in a doctor’s panel (those patients who have an established relationship with the doctor).
In the new SaPP process, our HICs:
The SaPP is a crucial component of the support we provide — helping to improve patient outcomes and ensure no one falls through the cracks.
Continued nursing support for patients
Our Chronic Disease Management program provides essential support to patients through nursing appointments, senior services, and maternity care.
Our Primary Care Registered Nurses (PCRNs) can provide a variety of care to patients. In addition to the top-referring conditions like diabetes and heart disease, our nurses are able to support with:
- Goal setting and health promotion
- Mental health screening and intervention
- Menopause education
- Building patient confidence in self–management of their health condition
- Perinatal support
- Cognitive screenings
- And more
Several of our nurses also worked to expand their knowledge this year by completing additional training, including Certified Diabetes Educator (CDE), Certified Respiratory Educator (CRE), Certified Bariatric Educator (CBE), and more.
This training will be used to further support our patients with key concerns. You can learn more about the nursing support we provide on their dedicated web page.
This work is greatly appreciated by our patients, with our annual Patient Experience Survey showing:
of respondents who had an appointment with a PCRN or Senior Services Registered Nurse said their provider explained things in a way that was easy to understand, involved them in their care decisions, and listened carefully to their needs.
of respondents who had an appointment with a Senior Services RN were very satisfied or satisfied with the care they received.
of respondents who had an appointment with a PCRN were very satisfied or satisfied with the care they received.
Membership Check-in Survey results
From September to November 2024, we administered our annual Membership Check-in Survey with members to gather feedback on our Patient’s Medical Home (PMH) programs and teams.
The survey included two sections:
A self-assessment tool to promote reflection on progress in building a strong PMH — meaning a connected and collaborative network with other health care providers who work together to support patients.
- 84 per cent of respondents scored within the “Strong PMH” range
A new Health Team Effectiveness (HTE) tool to assess the strength and functioning of primary care teams.
- Strong HTE scores were reported, with an average of 4.3 out of 5, suggesting that primary care team members generally view their team as effective
Average PMH score
Average HTE score (out of five)
These strong scores indicate our members feel their PMH and health teams are effective and strong. We are encouraged by these results and will continue to use this feedback to improve our programs and services.
Members also had the opportunity to discuss their survey results with an expert quality improvement facilitator in a personalized session. The lessons from their session could be used to identify and act on an improvement opportunity.
Continued CII/CPAR support
This year, we continued to support all our members with onboarding to the Community Information Integration & Central Patient Attachment Registry (CII/CPAR) as part of our Panel Support Program.
This support became particularly important in December 2024 when the Government of Alberta and Alberta Medical Association announced a new physician funding model that required onboarding to CII/CPAR.
Our Health Information Coordinators (HICs) and Quality Improvement Coordinator (QIC) work together to support members with their onboarding — including providing funding information, completing key paperwork, and more.
This work ensures continuity of care for patients, as CII/CPAR allows for the sharing of information between all providers in a patient’s circle of care. As of 2024, the majority of our members have been onboarded to the program, and we will continue to provide support as needed.