Patient Medical Home

A PMH connects patients to the care and support they need when they need it.

A PMH consists of a family doctor, the multidisciplinary team supporting them, and allied healthcare providers. Delivering seamless care centred around patients’ needs – at every stage of life – CWC PCN staff work directly with physicians and their patients to ensure continuous, effective medical care.

Highlights from 2020-21

Our PMH team provides…

Patient Medical Home teamsIf your family doctor is a member of the CWC PCN, their PMH may include members of our Patient Care Team such as nurses, mental health professionals, and other clinical professionals.
Data and analyticsOur teams use an evidence-informed approach to identify and implement clinic processes that promote patient care and management.

Quick to pivot

In the pandemic’s onset, no one knew what was coming next – but we did know we would have to pivot and adapt.

When COVID-19 was declared a global pandemic in mid-March, our Patient Care Team immediately moved to digital care. We quickly implemented new virtual processes to maintain the highest quality of care, safety, and security for our staff and patients.

Through this, our clinical staff were busier than ever. In January 2021, our Behavioural Health Consultants and Primary Care Registered Nurses had 2,315 encounters with patients, up from 1,797 the previous January (a 29 per cent increase).

Some of our Patient Care Team began using a virtual-first approach in November 2020. Taking precautions, they see patients in person only if the patients’ needs cannot be met virtually.

Answering the call for mental health services

As the COVID-19 pandemic changed the way we work and live, many Calgarians experienced heightened stress and emotional challenges. The need for mental health services increased, and the CWC PCN swiftly took steps to address the community’s needs.

Building from within

Internally, we increased our capacity to support mental health services.

We built capacity within our clinical team by welcoming nurses with working knowledge and proven experience as mental health professionals. We also created an instrumental new role — the Mental Health Program Coordinator — to help us unify the CWC PCN’s mental health services and partnerships.

We also created Mental Health Assist, a single-session virtual care program staffed by a team of Registered Nurses with proven mental health care experience. During a free sixty-minute session — by phone or by video — our compassionate nurses listened to patient concerns, assessed the patients’ needs and goals, and connected them to further resources if needed.

Branching into the community

In February 2020, we initiated a pilot project with the Calgary Counselling Centre to provide additional mental health support for members of our community.

Through the pilot, physician members could refer their patients to the Calgary Counselling Centre at no expense. With CWC PCN-reserved practitioners, patients could see a counsellor for free and quickly.

In addition, we partnered with the Canadian Mental Health Association – Calgary Region (CMHA Calgary) and offered a series of exclusive mental health courses at no cost to patients. In July 2020, we hosted Coping with Discomfort, a session that helped patients strengthen relationships, reduce isolation, and find their voice during a challenging time.

Delivering more in teams of two

At the CWC PCN, we have experts in many fields.

Health Information Coordinators manage personal health information and interpret data to better care for patients. Patient Care Coordinators specialize in managing care coordination – with an emphasis on logistics – and administration.

In the past, the CWC PCN assigned either a Health Information Coordinator or a Primary Care Coordinator to our member clinics.

We began to realize these roles had two unique skill sets and could deliver the most by working best together.

In December 2018, we launched an 11-month pilot project. During this pilot, Health Information Coordinators and Patient Care Coordinators worked together virtually, supporting clinics as a single unit.

As participating staff and physician members provided feedback, we heard that this process was more efficient and enabled our team to seamlessly manage health information and patient care.

In response, we formalized this partnership in a Pair-Up Model. Now, physician members are assigned both a Health Information Coordinator and a Patient Care Coordinator to support their Patient Medical Home.

This change helps cover gaps and enables both positions to operate within the full scope of their role and to the full extent of their training. By cross-training these positions, they can work collaboratively and provide coverage during absences.

Because this model operates virtually, we fully implemented the Pair-Up Model in November 2020 with no interruption caused by the COVID-19 pandemic.

Patient Care Team

Health team effectiveness endures through tumultuous times 

A Health Team consists of a family physician member and CWC PCN employees who support them, including nurses and consultants.

To ensure we are supporting our members and our teams to the best of our ability, we collect data on CWC PCN Health Teams’ overall performance.

Because 2020 was such an unusual year, in October 2020, we asked physicians two questions:

  • How they felt our healthcare team functioned before the pandemic.
  • How they felt our healthcare team performed during COVID-19 while working in a high-intensity, virtual environment.

Physicians ranked their Health Team on a five-point scale that explored topics such as communication, collaboration, and innovation. Health Teams that were ranked a four or higher are considered high-functioning.

We saw a pre-pandemic increase in team performance this year, and then a decrease after the pandemic, likely due to rapidly changing working protocols and new processes to ensure patient safety.

We will always strive to deliver the most – for our members and their patients. While we are extremely happy with these results, our goal for the next year is to achieve an average score above 80 per cent.

Your browser does not support the HTML5 canvas tag.
October 2019
Your browser does not support the HTML5 canvas tag.
October 2020
of teams demonstrated they functioned
effectively prior to the pandemic
Your browser does not support the HTML5 canvas tag.
October 2020
of teams demonstrated they functioned
effectively during the pandemic

An improved patient experience  

To understand our patients’ ongoing health needs and to evaluate the care received from the patient’s perspective, the CWC PCN asks patients to report on their experience with CWC PCN employees.

In September 2020, 262 patients across 37 of the 43 eligible member clinics (approximately 86 per cent) completed a survey on criteria surrounding patient-centred care and perception of the care they received.

Ninety-three per cent of patients rated their overall quality of care received from CWC PCN providers as very good or excellent.