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Medical Home

Medical Home

Most Albertans are part of a Medical Home, a team of health care professionals that prompt screening and help manage your care.  When you see your family doctor, you will be asked if you are their patient in order to confirm your medical home.  This foundation improves your access, increases services and ultimately offers you better care.

Licensed Practical Nurses working within the Medical Homes will help you keep current on most health screens such as flu shots and blood pressure checks.

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.