Building the Patient's Medical Home in Alberta

The Patient’s Medical Home (PMH) is a vision for the future of family practice in Canada. In this vision, every family practice across Canada offers the medical care that Canadians want — seamless care that is centred on individual patients’ needs, within their community, throughout every stage of life, and integrated with other health services (College of Family Physicians of Canada).

About the PCN-Level Medical Home Assessment Tool

In Alberta, the Primary Care Network PCN-Level Medical Home Assessment tool was developed to help PCNs understand their current level of capacity to support their member clinics achieve the Medical Home model.  

The PCN-Level Medical Home Assessment was designed to be used with the support of a facilitator to guide teams through their assessment and action planning processes.  

The PCN-Level Medical Home Assessment Tool

  • Is a practical tool to assess PCN level processes, structures, activities and programs related to PCN Evolution and Medical Home concepts.

  • Is a resource to help PCNs prioritize and plan quality improvement activities, and encourages shared conversation between the Board and PCN leadership about priority areas.

  • Can provide an approximation of where resource investment may be needed for clinics/practices to make the journey towards a medical home.

  • Can be integrated with business and strategic planning, as the medical home model is aligned with the goals and principles set out in Alberta’s Primary Health Care Strategy.

  • Can assist PCNs in tracking progress toward PCN Evolution and Medical Home transformation at regular intervals (e.g. annually), as the tool can be PCN-initiated at a later time.

  • Can be used by the PCN to set priorities and to create a customized Action Plan that outlines actions and supports to be further developed.

Who can participate in the Medical Home Assessment?

  • Each PCN is invited to complete the PCN Level Assessment.

  • In order to capture the perspectives of individuals with different roles within the PCN, it is recommended that the assessment be completed by as many PCN team members as possible. Having multiple perspectives from different functional areas will provide a greater picture of how things operate within the PCN.

  • Ideal participants in the Medical Home Assessment may include the Executive Director, at least one Board Member, Lead Physician(s), and other senior staff (e.g. Clinical Managers, Facilitators, Directors, Evaluator, etc.).

Time commitment for the Medical Home Assessment Tool:

  • The Executive Director (or assessment sponsor) will be asked to meet with the Facilitators for a 30-minute phone call to discuss the process and answer questions.

  • The assessment tool will take each participant approximately 30 minutes to fill out individually.

  • Following individual completion, all participants will meet with Facilitators for 2 hours to generate consensus scores.

Support available while completing the Medical Home Assessment:

  • During the initial assessment, the consensus-building process will be facilitated by PMP and PCN PMO teams.

  • Should the PCN complete follow-up assessments at a later time, the PCN can decide whether to hire an external facilitator or have a neutral internal staff member take over this role.

  • The PMP and PCN PMO teams will be available to work with PCNs to complete the assessments, guide action and quality improvement planning, and provide links to provincial programs.

  • PCNs will be provided with tools to provide assistance with identifying action items and templates and supports for developing their own action and change management package.

  • Assessment results are owned by each PCN; although a facilitator will be assigned to assist your PCN in completing the tool and prioritizing activities, the facilitator will not keep a copy of results.


It is recommended that PCNs begin with System Level Supports, Laying the Foundation and Building Relationships so as to better support the practice-level Medical Homes. Next steps include Changing Care Delivery and Reducing Barriers to Care. (Pages for each step to be developed)

Resources for these topics are available by selecting the appropriate spoke on the PCN Evolution support interface