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 2025-26
Our PMH team provides…
Launch of Health Status Surveys
In 2025, our PCN launched a Health Status Survey project to help measure patient outcomes across clinical programs. The Short Form-12 (SF-12) survey tool selected for this project is a Patient-Reported Outcome Measure (PROM) designed to assess a patient’s overall health status and quality of life.
Using this model, a patient is sent the survey prior to their first appointment with a provider. After a set number of days, the patient is sent a follow-up survey to determine how their health status has changed over time.
The SF-12 survey allows us to gather insights into patient health that are not captured by traditional clinical metrics. This helps us track changes in patient well-being over time to support learning and planning.
The questions outlined in the survey assess different aspects of the patient’s physical and mental health. The survey was rolled out gradually across our clinical teams to allow for testing and refinement of implementation.
Early results from the first three clinical teams show:
- On average, respondents who had appointments with a Primary Care Registered Psychologist had an increased mental health score. This higher score indicates better health outcomes (8.8-point change).
- On average, respondents who had appointments with our Senior Services team and Social Workers had an increased mental health score (6- and 4-point change, respectively).
As these surveys are still new, these results are based on smaller sample sizes (67 responses from PCRP patients, 19 from Social Worker patients, and 10 from Senior Services). Further data collection will allow us to observe more definite trends over time. The survey was additionally rolled out to our Primary Care Registered Nurses’ patients in December 2025, and we look forward to sharing results in future reports.
Overall, the Health Status Survey responses have been valuable to us as we look to better understand the change in our patients’ health and well-being during their care journey with our clinicians.
Continued mental health support for patients
In 2024, our highly used Mental Health Program expanded to offer evening and weekend appointments with our Primary Care Registered Psychologists (PCRPs). This expansion has improved patient care by allowing community members to access no-cost counselling services at a time that works best for them.
Our 2025 Patient Experience Survey highlighted the value of these appointments, with 92 per cent of respondents with an evening or weekend appointment agreeing or strongly agreeing that these options enabled them to access services they would otherwise not be able to access.
Feedback included that the greatest value of the PCRP role was “helping people move forward if they get stuck” and being “a very good listener.”
Recent engagement sessions with doctors in our membership further emphasized the importance of our Mental Health Program and PCRPs, with participants stating that PCRP support was an incredibly valuable resource for their practice, benefiting both patients and physicians.
Patients served through extended-hours PCRP appointments from April 1, 2025, to April 1, 2026
Transitioning CII/CPAR support
Our PCN has a team of Health Information Coordinators (HICs) and Patient Care Coordinators (PCCs) who support doctors in our membership through the facilitation of screening projects. These vital screening projects help catch chronic diseases early, directly supporting the well-being of our community.
Over the past several years, our HICs and PCCs have also supported members with onboarding to the Community Information Integration & Central Patient Attachment Registry (CII/CPAR).
This work was an important part of patient care, as CII/CPAR enables information sharing among providers in a patient’s circle of care. This support ended in 2025, as the majority of the doctors in our membership had been onboarded to the program.
Our HICs and PCCs have since worked collaboratively with clinics to help them transition the management of post-onboarding CII/CPAR-related work to their internal teams. This transition has increased capacity for screening project support, with overwhelmingly positive feedback from our doctors.
High satisfaction with our Nursing Program
Our Primary Care Registered Nurses (PCRNs) support patients through virtual appointments after a referral from their doctor. In these appointments, PCRNs help patients manage their chronic conditions through education, empowerment, and support with key lifestyle changes.
In September 2025, our PCN completed a physician engagement project to better understand the value our PCRNs provide to members and identify potential areas for improvement.
Feedback from interviewed doctors highlighted:
- How valuable the support of their PCRN was, with many describing their PCRN as having a significant impact on the team-based care their patients receive.
- That PCRN support enhanced patient care by providing follow-up appointments, ongoing condition management, and detailed disease education.
- They could rely on their PCRN to provide health information and education to patients, allowing them to better understand and manage their health conditions.
This project demonstrates the value our PCRNs bring to doctors in our membership and their patients.
“Having this kind of data at my fingertips allows me to understand trends and make informed decisions to ensure that our resources are allocated where they will be most efficiently used.”
— Jeremy Barham,
Manager – Mental Health Program
Enhanced internal reporting for clinical programs
In 2025-26, our Data Management & Evaluation (DME) team developed clinical program dashboards for our Patient’s Medical Home (PMH) managers to review on a monthly basis.
The dashboards include data relating to:
- Total number of monthly referrals, including referral status and the number of referrals from each doctor in our membership.
- Total number of monthly appointments offered to patients, including appointment type and status.
- Information on clinical time utilization, allowing managers to see the distribution of time dedicated to patient care versus administrative tasks.
- Patient data, including basic demographic information, Patient Experience Survey data, and Health Status Survey data.
This method provides managers and the DME team with summarized information from across multiple clinical programs in one standardized set of reports. The dashboards allow PMH managers to easily access information about their programs to help guide decision-making and improvements.
Automatic subscriptions send these reports to managers and directors every month once data are updated to help them stay on track with their programs.