Alignment of Canadian Primary Care With the Patient Medical Home Model: A QUALICO-PC Study

Alan Katz; Nicole Herpai; Glenys Smith; Kris Aubrey-Bassler; Mylaine Breton; Antoine Boivin; William Hogg; Baukje Miedema; Jocelyn Pang; Walter P. Wodchis; Sabrina T. Wong

doi:10.1370/afm.2059

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Figure 1
Average crude patient medical home scores in the Canadian provinces.
AB = Alberta; BC = British Columbia; MB = Manitoba; NB = New Brunswick; NL = Newfoundland/Labrador;
NS = Nova Scotia; O = Ontario; QC = Quebec; PEI = Prince Edward Island; SK = Saskatchewan.
Note: Error bars represent 95% confidence intervals.
^aDenotes a significant difference (P <.05) from the national average.

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Table 1

The 10 Goals of the Patient Medical Home Model

1. Patient centered	Provide services that are responsive to patients’ and their families’ feelings, preferences, and expectations
2. Personal family physician	The most responsible provider of a given patient’s medical care Every person in Canada should have a personal family physician
3. Team-based care	Offer a broad scope of services carried out by teams or networks of clinicians; inclusive of nurses, peer physicians, and others
4. Timely access	Timely access to appointments in the practice Advocate for and coordinate timely appointments with other health and medical services required
5. Comprehensive care	Provide a comprehensive scope of family practice services by working collaboratively with other professionals Address public health needs Taking population health effects into account
6. Continuity	Offer continuous care over time and in different settings Advocate on the patients’ behalf for continuity of care throughout the health care system Preserve constant relationships and continuous medical information for patients
7. Electronic records and health information	Maintain electronic medical records
8. Education, training, and research	Serve as a model place for training students, residents, and other health professionals Carry out and/or encourage staff to be involved in primary care research
9. Evaluation	Carry out ongoing evaluation as part of the commitment to continuous quality improvement
10. System support	Internal support through governance and management structures External support by stakeholders, the public, and other medical and health professionals and their organizations across Canada

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Table 2

Practice Characteristics Included in the Statistical Model

	No. (%)
Community size
Large city center	238 (30.36)
Suburbs	133 (16.96)
(Small) town	152 (19.39)
Mixed urban-rural	107 (13.65)
Rural	154 (19.64)
Funding model
New model of primary care with special funding	421 (53.16)
Traditional model	371 (46.84)
Practice population size
≤800	185 (23.36)
801–1600	310 (39.14)
1,601–2,400	162 (20.45)
2,401–3,200	71 (8.96)
>3,200	64 (8.08)
Wait time between scheduled appointment and consultation
<15 min	3,592 (50.08)
15–30 min	2,074 (28.92)
31–45 min	630 (8.78)
>46 min	481 (6.70)
Hours of operation
Clearly indicated outside office entrance	480 (62.18)
Not clearly indicated	276 (35.75)
How to get care outside of office hours
Clearly indicated outside office entrance	216 (27.98)
Not clearly indicated	526 (68.13)
Parking for people with disabilities
Yes	684 (88.6)
No	81 (10.49)
Physical accessibility of practice
Ground floor	477 (61.79)
Elevator	255 (33.03)
No elevator/not ground floor	35 (4.53)
Physical access for patients with a wheelchair or stroller
Very easy	453 (58.68)
Easy	273 (35.36)
Difficult/Impossible to access	46 (5.96)
Accessible toilet for patients with disabilities
Yes	672 (87.05)
No	87 (11.27)

Note: All practice characteristics were included in the model regardless of their significance (P <.05). Practice characteristics related to physical accessibility (last 6 characteristics above) were combined into 1 variable, “superior access.” The reference category for practice population size was 801–1600, as this response was most common. For wait time, we calculated each practice’s average wait time. Québec was chosen as a reference category for province because it represented the largest sample.

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Table 3

QUALICO-PC Surveys Undertaken in Each Province

Province	Family Physician No.	Practice No.	Patient Experience No.	Total by Province No.	Completion Rate %
Ontario	184	183	1,698	2,065	81
British Columbia	59	58	537	654	84
Newfoundland and Labrador	41	41	320	402	57
Alberta	116	117	1,240	1,473	70
New Brunswick/PEI	54	53	497	604	70
Saskatchewan	20	20	185	225	77
Nova Scotia	59	58	544	661	75
Manitoba	41	24	353	418	67
Québec	218	218	1,798	2,234	84
Total surveys by type	792	772	7,172

PEI = Prince Edward Island; QUALICO-PC = Quality and Costs of Primary Care.
Note: Completion rates calculated as the number of physicians who completed the survey package divided by the number of physicians who received the survey package.

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Table 4

Adjusted Mean Differences in Patient Medical Home Scores Among Canadian Provinces, Using Québec as the Reference Province

Patient Medical Home Goal	Mean Differences (95% CI)				Mean Differences (95% CI)

	Ontario	British Columbia	Newfoundland/Labrador	Alberta	New Brunswick/Prince Edward Island	Saskatchewan	Nova Scotia	Manitoba
Patient medical home (overall)	1.48 (1.33 to 1.63)^a	0.84 (0.62 to 1.05)^a	0.01 (−0.23 to 0.26)	0.63 (0.46 to 0.80)^a	0.10 (−0.13 to 0.32)	0.39 (0.04 to 0.74)^a	0.78 (0.56 to 0.99)^a	0.50 (0.25 to 0.75)^a
Patient centered	1.03 (0.31 to 1.75)^a	0.90 (−0.16 to 1.95)	0.52 (−0.71 to 1.74)	1.64 (−2.43 to −0.84)^a	0.46 (−0.63 to 1.54)	0.69 (−0.99 to 2.37)	0.78 (−0.27 to 1.83)	−0.54 (−1.76 to 0.69)
Personal family physician	2.37 (1.53 to 3.20)^a	2.31 (1.08 to 3.54)^a	1.26 (−0.17 to 2.68)	−0.71 (−1.64 to 0.21)	1.16 (−0.10 to 2.42)	1.58 (−0.37 to 3.54)	1.67 (0.45 to 2.89)^a	1.73 (0.31 to 3.15)^a
Team-based care	−0.34 (−1.20 to 0.51)	−0.96 (−2.22 to 0.29)	−0.79 (−2.25 to 0.66)	−2.44 (−3.38 to −1.49)^a	−0.04 (−1.33 to 1.25)	−1.60 (−3.60 to 0.39)	−0.40 (−1.64 to 0.85	−4.88 (−6.34 to −3.43)^a
Timely access	1.69 (1.10 to 2.28)^a	0.39 (−0.48 to 1.26)	−0.19 (−1.20 to 0.82)	−0.59 (−1.24 to 0.07)	−1.40 (−2.29 to −0.51)^a	−0.06 (−1.44 to 1.32)	0.02 (−0.84 to 0.88)	−1.07 (−2.08 to −0.07)^a
Comprehensive care	3.88 (2.06 to 5.69)^a	7.42 (4.75 to 10.09)^a	6.34 (3.25 to 9.44)^a	−2.36 (−4.37 to −0.35)^a	1.88 (−0.86 to 4.63)	6.92 (2.67 to 11.17)^a	4.01 (1.36 to 6.66)^a	1.87 (−1.22 to 4.97)
Continuity	1.14 (0.83 to 1.45)^a	1.56 (1.10 to 2.01)^a	0.72 (0.19 to 1.24)^a	0.66 (0.32 to 1.00)^a	0.98 (0.51 to 1.45)^a	0.88 (0.16 to 1.60)^a	1.29 (0.84 to 1.75)^a	1.05 (0.52 to 1.57)^a
Electronic records and health information	2.73 (2.34 to 3.13)^a	2.28 (1.70 to 2.86)^a	0.07 (−0.61 to 0.74)	2.32 (1.87 to 2.78)^a	−0.30 (−0.90 to 0.30)	1.63 (0.70 to 2.55)^a	1.79 (1.21 to 2.37)^a	2.75 (2.08 to 3.42)^a
Education, training, and research	−0.18 (−0.75 to 0.40)	−0.08 (−0.92 to 0.75)	−0.59 (−1.57 to 0.39)	−0.21 (−0.86 to 0.45)	−0.44 (−1.31 to 0.42)	0.23 (−1.10 to 1.56)	0.05 (−0.79 to 0.89)	0.01 (−0.96 to 0.98)
Evaluation	2.22 (1.89 to 2.56)^a	1.56 (1.07 to 2.05)^a	−0.22 (−0.80 to 0.35)	1.16 (0.78 to 1.55)^a	0.22 (−0.29 to 0.73)	0.47 (−0.32 to 1.25)	1.31 (0.81 to 1.80)^a	1.73 (1.16 to 2.30)^a

Note: Estimates are adjusted for variables shown in Table 2.
↵a Values are significantly different (P <.05) from the reference province (Québec).

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The Article in Brief

Alignment of Canadian Primary Care With the Patient Medical Home Model: A QUALICO-PC Study

Alan Katz , and colleagues

Background Canada's patient medical home (PMH) model includes ten goals that enable the best possible health outcomes for patients and communities, while emphasizing Canadian health care values. This study aims to determine to what extent the structure and processes that define primary care in Canada align with PMH model goals.

What This Study Found Evaluating the degree to which primary care across Canada comports with the goals of the Patient Medical Home model, researchers find considerable room for improvement. Ten measurable indicators of the PMH model were applied across all 10 Canadian provinces. The results indicated an average national PMH composite score of 5.36 out of 10. Ontario was the only province to score significantly higher than Canada as a whole, while Quebec, Newfoundland/Labrador, and New Brunswick/Prince Edward Island scored below the national average. There was little variation among provinces in achieving the 10 PMH goals. Although the PMH is a pan-Canadian model, implementation is dependent on provincial and regional or local policies, and during the past 15 years, new primary care funding models have been introduced without consistency in timing, key model components or implementation strategies across provinces.

Implications

The authors call for future research into the effects of reform on practice characteristics and processes, and assessment of health services utilization and quality measures for clinical conditions. The information gained from these activities, they posit, may motivate further uptake of the PMH model's attributes in all provinces
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