| Redesign primary care practice to realize the principle of comprehensiveness |
Integrating behavioural health care, including substance abuse, mental health, and behaviour change support, into primary care delivery Integrating the primary care health system with community-based resources and the public health system Improving the primary care work force, work flow, information systems, and non-financial incentives to reduce inappropriate referrals to subspecialty care Enhancing care coordination with subspecialty care system for people with complex conditions Enhancing information systems, including clinical decision support, virtual consultations, and tele-mentoring to promote evidence-based care Broadening primary care practices to address the needs of both individuals and the community
|
| Adopt a patient-centred approach in which patients and caregivers are engaged in developing and implementing their care plans, as well as the design, ongoing evaluation, and improvement of primary care practices |
Providing robust patient self-management support and exercising shared decision making to empower patients to meet their personal goals Developing and using evaluation measures that align with patient goals for care and health Designing care plans that take into consideration multimorbidity and social context
|
| Reorient primary care to be delivered by primary care teams with diverse skill sets and an expanded range of competencies, and customize teams to the needs of the patient and community |
Engaging primary care practices and systems in continuous learning and ensuring they have the resources, staff, and skills needed to meet the specific needs of each individual patient and family Using data and meaningful measures to improve care, and addressing broader population health objectives and the social determinants of health Rekindling the “joy of practice” and ensuring the well-being of professionals and staff is not overlooked
|
| Improve and advance electronic health systems and quality measurement |
Ensuring primary care teams have access to the information and data they need to engage in continuous improvement, provide patient-centred care, and address population health Enhancing the capacity to use data captured in practice from patients to develop the evidence about what works both clinically and with respect to models of care delivery
|