Rural and Remote Division of Family Practice

Rural Patient Medical Home

Strengthening the Rural Patient Medical Home through Partnership Planning & Interdisciplinary Team-based Care

Provincially Funded PMH Initiative (2017-March 31 2019)

In our small rural communities where physicians provide the full spectrum of acute and community care, with limited numbers of physicians, a team-based approach to care is essential. For the majority our communities, patients are considered attached to a physician practice regardless of panel size and are not typically turned away from the physician’s office and as such patient attachment is not the issue but rather the quality of the attachment and access to comprehensive/longitudinal services. Many rural GPs are already actively collaborating in varying degrees with expanded interdisciplinary teams that may include other physicians, NPs, RNs, specialists and other care providers within a practice, facility, community and/or across a geographic region. Despite this, there are gaps in meeting the needs of some of our more vulnerable and complex patients. Further, there are unique barriers and challenges (i.e. limited providers) to the care we provide that are different to non-rural areas and subsequently the changes needed are also quite different. For example, the smaller the community, the broader the scope of services that are typically required of a physician and their team, even if where there is a hospital as it is often that same physicians from the community providing acute care services. 

The Division is focusing its efforts on two main strategies:

1.    Supporting our newer communities through an assessment and planning process that builds on the strengths of each community, while ensuring the necessary partnerships are in place to support unique interdisciplinary team-based improvements.

2.    The implementation of community specific interdisciplinary team-based initiatives that focus on addressing unique service delivery gaps related primarily to adults with complex medical conditions and/or frailty.

Our goal is for interdisciplinary team-based care to be supported by structures and processes that enable collaboration across all organizations and disciplines, while continuing to engage the patient voice, and ensure cultural safety and acceptability in care delivery.

We plan to achieve this by enabling and supporting unique interdisciplinary team-based innovations led by and rooted in strong, community-based primary care teams that have the potential to be spread to other rural and remote communities.  There will be a focus on adults with complex medical conditions and/or frailty as these are the patients in our communities most in need. Varying degrees of community readiness will be addressed through a flexible implementation plan that builds on the strengths of each community, while ensuring the necessary partnerships are in place to support unique interdisciplinary team-based work improvements. We know from our experiences in rural and remote communities that service flow and approaches to care delivery vary from community to community and that they are best created from the ground up to allow strong, collegial relationships to evolve.

Our work will continue at the grassroots, community level, and build momentum and collaboration with and through local, regional, and provincial relationships. Through locally focused and unique implementations we will support needed change and inform the requirements/enablers for spreading this change in other rural communities.

If you have any questions regarding our PMH work, please send us an email.