FHTs are...

locally driven Primary Health Care organizations that include Family Physicians, Nurse Practitioners, Nurses and a range of other health care professionals who are committed to working together to provide comprehensive, accessible, coordinated Primary Health Care services to a defined population.

Their mandate is to provide comprehensive Primary Health Care that is characterized by:

• Engagement of patients as informed decision-makers and in self-care


• Expanded access through a telephone health advisory service and extended hours of practice


• Effective system navigation and coordination of care


• An emphasis on health promotion, disease prevention, and early detection of illness


• A central role in coordinated chronic disease management and support for patient self-management


• Linkage to other community health care organizations and responsiveness to community needs


• Use of information technology to support system integration and coordination of care

Characteristics of the FHT Model of Family Health Care

There are six key domains that characterize the FHT model of care:

Population Approach

The population approach involves thinking about the entire population served by a FHT, rather than just the individuals who are seen or come for appointments. This may be everyone on the roster for preventive interventions, or specific sub-populations with particular health risks or problems. The Population Approach supports the implementation of comprehensive Health Promotion/Illness Prevention and Chronic Disease Prevention and Management (CDPM) programs and activities. It allows FHTs to conduct a comprehensive assessment of client requirements that may be currently unmet. This model enables attention to be given to community needs and social determinants of health.

Team-based Care

Team-based care reflects the care provided by a high-functioning interdisciplinary team that shares a common goal. The team draws upon the expertise and knowledge amongst its members, working collaboratively - and with clearly defined roles - in a supportive, respectful and effective way that is in tune with the needs of individual patients and the practice population.

Quality Improvement

Quality improvement results from a culture that strives to find ways to improve care, by supporting the continuing appraisal of services delivered and office practice efficiency. Once potential improvements are identified, the team can rapidly test out new ideas and evaluate them. The process offers the opportunity for further improvements as FHTs study any lessons learned along the way.

Performance Measurement

Performance measurement reflects the need for a FHT to understand its current functioning or performance. The team can also plan and monitor changes and innovations based on relevant and accurate data. This includes identifying the needs of the population it serves, measuring the impact of staff and programs, assessing the satisfaction and ideas for improvements of those using the services, and using these data to further improve performance.

Patient Engagement

Patient engagement refers to steps a FHT can take to involve patients and their families in all aspects of care, at both a clinical as well as an organizational level. It includes support for self-management of care, gathering patient input into how care is delivered, and patient satisfaction with the way the FHT serves them. A key component is to involve patients in the planning and development of services. Patient engagement promotes patient-centred care.

Community Partnerships

Community partnerships optimize many of the programs and services FHTs provide by ensuring they work closely with local health and community service partners who offer complementary services. This collaboration promotes integration of services across organizations. Partnerships lead to more effective and better coordinated care. As a result, patients gain easier access to the services they require and FHTs are able to build healthier communities. In the process, the partnering teams become advocates for policy changes that support further collaboration.