A health home is a patient‑centred, team‑based model of primary care in which family medicine specialists work in close collaboration with other health professionals, such as nurse practitioners, family practice nurses, pharmacists and social workers, to provide comprehensive and coordinated care. This is not an all-encompassing list of providers who may be a part of a health home, as all teams should be built based on community needs. Health homes are not always a centralized physical location, but most often an integrated, collaborative approach designed to better support the health needs of a community.
The health home model is a well-known model of care globally, and the benefits are well documented. Health homes provide better patient care at a lower cost, better meet community needs and are a more sustainable model for healthcare providers, particularly family physicians.
Family physicians are central members of health home teams and bring a unique perspective on what helps team-based care succeed. Drawing on physicians’ experiences delivering care in communities across Nova Scotia, the paper offers practical recommendations to strengthen health homes and help ensure they reach their full potential for patients, providers and communities.
The recommendations focus on key areas such as governance, compensation, infrastructure, interoperability, collaboration, patient education and change management.
This paper comes at an important time. Nova Scotia has made significant progress in building and strengthening team-based care. Existing health home practices (or, more accurately, team-based practices) vary; some are more robust, more mature or better resourced than others, and all would benefit from additional support. The government has reported that more than 120 health homes have already been established across the province. Additionally, Nova Scotia Health’s (NSH) commitment to supporting interprofessional teams has provided valuable insights into the factors that contribute to effective team-based practices and created a foundation for ongoing improvements. We are also encouraged by the investments being made to stabilize primary care and the shared, system-wide commitment to continuous improvement.
Doctors Nova Scotia (DNS) recommends:
- Share a clear vision for health homes – System partners, DNS, family medicine specialists and other primary care providers should align around a shared definition and implementation strategy for health homes in Nova Scotia.
- Have all primary care partners at the table – Create a provincial coordination working group that supports the implementation and oversight of health homes in the province through setting definitions and policies, ensuring role clarity (for both provider and system roles), supporting collaboration, identifying gaps and opportunities for improvements, and sharing best practices.
- Support interprofessional best practices through appropriate compensation – Allow physicians to participate fully in the collaborative and team-based health home by removing the financial disincentives and fostering interdisciplinary best practices, ensuring that physicians are compensated for time spent team-building, collaborating, mentoring, making decisions and resolving conflicts within a health home.
- Design physical infrastructure that supports teaching and mentoring – Work directly with providers and community to build, redesign or enhance existing infrastructure to ensure that health homes are designed for optimal team-based healthcare delivery.
Infrastructure decisions must include space for learners, since health homes must serve as training sites for medical students, family medicine residents and those training to become nurses, nurse practitioners and other health care providers. - Share health information between providers – Implement a digital health solution in primary care to ensure that health homes and all other care settings are connected to OPOR, and providers can access and contribute to the medical record to care for patients in all care settings.
- Move past episodic care – Ensure existing episodic care access points are connected to a health home, and transition to becoming part of a patient’s medical neighbourhood.
- Embrace clinical leadership by family physicians – Health homes should be clinically led by family medicine specialists, leveraging their expertise in managing complex cases and delivering longitudinal and integrated care to ensure coordinated, patient-centred outcomes.
- Be driven by community need – When establishing a new health home, a community health needs assessment be completed to ensure that community needs are met. Ideally, this should be done jointly between family physicians and NSH in consultation with other providers and community.
- Provide education and change management support for patients and providers – The government should educate the public about the benefits of health homes, and what Nova Scotians can expect when they are a patient in a health home.
- Change management – When establishing a new health home, or transitioning an existing clinic into a health home, family physicians and other providers should be provided with change management support to optimize the implementation and adoption of health homes.
Optimizing health homes requires a shared vision, strong clinical leadership by family medicine specialists, robust interprofessional collaboration, interoperable digital infrastructure and meaningful engagement with communities to ensure care is tailored to local needs.
Equally important are the supports required to manage change for patients, physicians and care teams within a healthcare system already experiencing significant transformation.
Doctors Nova Scotia is encouraged by the shared commitment among healthcare partners to continuous improvement and remains dedicated to working with the provincial government, NSH, physicians and other partners to advance these recommendations. By strengthening health homes now, Nova Scotia can build a more integrated, sustainable and patient‑centred primary care system – one that delivers better health outcomes for all Nova Scotians.