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Medical Home

Medical Home

All over Red Deer and surrounding area people are contacting their doctors' clinics for appointments as they always have. But for the last 10 years they may have noticed access to other health care professionals right in their family doctor's office and access to other services at the RDPCN centralized office. The clinics have been evolving into Medical Homes. Over the past year RDPCN support nurses have worked with doctors to develop a system to identify their patient panel (list). In these clinics each time a patient comes in they are asked to verify their family doctor. It's a simple yet important step in sorting out the panel or list of patients connected to a doctor. The support nurses then identify which patients are due for screening tests such as pap smears and colon cancer tests. They then call the patients and set up appointments — something  called outreach screening. This is only one part of the behind the scenes work in the evolving Medical Homes.

The Patient's Medical Home has been in development for the past 10 years. The progress we've made to date includes:

  • Patient-Centered care that focuses on the whole person:  Once a person is connected to RDPCN they have access to a web of care.

  • Engaged Leadership: 10 family doctors and 2 community members sit on the RDPCN Board which sets the strategy for the PCN. Two Alberta Health Services employees sit on the governance committee.

  • Team-based Care: A family nurse, mental health counsellor and pharmacists see patients in doctors' clinics. A recreation therapist, pregnancy and babies nurse and group programs are available at the centralized PCN office.

  • Culture of Improvement: Evaluation is used to guide the continuous quality improvement process to ensure our programs are effective, meeting the needs of the community and using our resources wisely. All programs are evaluated and the results are reported to staff, doctors, the community, and Alberta Health.

  • Access to Care: RDPCN began tracking time to next appointment for doctor appointments in 2015 – 2016. Many doctors offer same day access to appointments.

  • Coordinated Care: Patients benefit from connections to community and AHS resources. 1,626 separate navigations were recommended to patients by RDPCN staff in 2015 – 2016.

  • Panel & Continuity: Physicians and teams know whose care they're responsible for. Two support nurses began working with clinics to develop processes for identifying, maintaining and managing patient panels.

  • Organized Evidence-Based Care: Evidence- based guidelines are embedded into the daily practice of doctors and other health care providers.