Family Medicine Matters

A Message from OCFP President Dr. Jennifer Young

January 25, 2019


Photo of OCFP 2018-19 President Dr. Jennifer Young

My fellow family physicians,

Our patients need us. Sometimes those needs are straightforward, such as advice on self-care or a simple prescription. Other times, their needs are more complex and require additional supports and expertise.

As the saying goes, “it takes a village to raise a child”. Similarly, for our patients, it takes a neighbourhood to provide their best care.

You may be familiar with the terms Patient's Medical Home or Patient's Medical Neighbourhood? They refer to a vision or ‘North Star’ for primary care, established based on evidence over a decade ago by our national College.

In this vision, the family doctor is the central point of contact for the patient and the primary coordinator of that patient’s care. Surrounding them is a responsive health hub or Patient's Medical Home (PMH) – the team members and services required for optimal patient care, such as social workers and pharmacists. Right now, team-based care is mostly offered in FHTs and CHCs, however there are other innovative ways to create teams in primary care.

The PMH is part of a Patient's Medical Neighbourhood (PMN) – a broader community that includes other sectors and settings such as hospitals, home care, mental health care programs and centres, addiction services, rehabilitation, walk-in services, long-term care, community care, public health, and so on.

This vision is gaining traction in Ontario and with other provincial governments looking to address health system challenges such as access, patient experience and physician wellness (burnout). And for good reason. A 2015 study published in JAMA shows that a medical home intervention was associated with improvements in quality of care, increased primary care utilization and lower use of the ED, hospital and specialty care. And hot off the press is another JAMA study showing that team-based care for chronically ill patients in a medical home reduces hospitalizations, emergency department visits and ambulatory care-sensitive emergency department visits.

We know there are still several barriers in the way for this vision to become a reality for all practices, and the OCFP is working to address this.

Of note, more than 70 per cent of family physicians often work without the multidisciplinary team support that more easily enables the concept of team-based care within the PMH. At our PMH Symposium in 2016, the most common needs for the core care team included a social worker; integrated EMR, data, and IT support; a case manager/care coordinator; and either a registered nurse or nurse practitioner. In response, the OCFP has continued to advocate for more equitable access to these essential team members and resources that were identified by our members and patients.

Family physician leadership has been and will continue to be essential in the success of system changes, as we know a top-down approach will fail (other jurisdictions have already proved this). In my own community of Collingwood for example, family physician leadership has produced a system where I can message pharmacists, home care and nursing homes in my area, while ER and hospitalist doctors from our local hospital can also access my patient’s office chart. Physician buy-in to this system has been easy because these leaders know our community’s needs, it has improved our clinical work and makes patient lives better in a very tangible way.

The OCFP continues to share our evidence and informed knowledge about the value of team-based care with policymakers. Our members are part of the tables that are making changes in their communities and at the provincial level. We want to make it easier for all of you to be that family physician who provides continuity and comprehensive care for your patients. We are working to fulfill our mission of “Supporting Ontario family physicians through education, leadership, research and advocacy, to deliver high-quality health care.”

I would greatly welcome your feedback. Write me at [email protected] or feel free to answer these two quick questions below.