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Where to Start

Safety Net Medical Home Initiative

Change Concepts: Organized, Evidence-Based Care

The guide introduces the Chronic Care Model and examines the connections between it and the PMH, and then focuses on critical aspects of organized, evidence-based care, including planned care, decision support and care management. Key changes for Organized, Evidence-Based Care include the following:

  • Use planned care according to patient need.
  • Identify high-risk patients and ensure they are receiving appropriate care and case management services.
  • Use point-of-care reminders based on clinical guidelines.
  • Enable planned interactions with patients by making up-to-date information available to providers and the care team at the time of the visit.



Comprehensive Primary Care Initiative

Topic-Specific Implementation Guides:

  • Care Management (pg 2-34)
  • Risk Stratification (pg 35-57)
  • Shared Decision Making (pg 58-84)

This guide reflects on how CPC practices across the country have approached care management. These practice strategies represent samples of the work and are not representative of every strategy for implementing robust care management in a practice. This Guide captures the energy, innovative ideas and rigorous and determined execution of the CPC practices as they tested and implemented care management in their practice.



Further Resources

Chronic Disease Management

Health Quality Ontario

Quality Improvement: Chronic Disease Prevention and Management e-Learning Module

A series of five online learning modules.


Quality Compass: Primary Care

The Quality Compass provides best practices and tools related to topics from the primary care Quality Improvement Plans, including post-discharge follow-up, diabetes care and others.


College of Family Physicians of Canada

Best Advice Guide: Chronic Care Management in the Patient’s Medical Home

This guide provides actionable advice to family physicians about chronic care management in all types of family practice settings. With proper intervention and ongoing care family doctors can help prevent and control the impacts of chronic diseases by implementing practical chronic care management strategies in their practices.



Palliative Care

Ontario Palliative Care Network

Palliative Care Toolkit

The resource offers best-practice tools to support primary care providers in the delivery of palliative care.


Cancer Care Ontario

Palliative Care Toolkit for Indigenous Communities

This toolkit includes resources and reference material for First Nations, Métis and Inuit families and communities. It can be used to help support people with cancer who have palliative care needs. These education materials can be used by anyone in the community.


Advance Care Planning in Ontario—A Quality Improvement Toolkit

This toolkit is for primary care practices that choose to include ACP in their annual Quality Improvement Plan.


Hospice Palliative Care Ontario

Health Care Consent and Advance Care Planning Community of Practice

ospice Palliative Care Ontario’s Health Care Consent and Advance Care Planning Community of Practice (HCC ACP CoP) is fast becoming the Centre of Excellence for HCC ACP in Ontario and is supporting the integration of HCC ACP into practice utilizing the Ontario legal framework. Membership supports the dissemination of reliable and accurate information that complies with HCC ACP in Ontario.


Speak Up Ontario

Ontario Toolkit

This resource includes tools for health care consent and advance care planning.



Home Visits

Ontario College of Family Physicians

House Calls 101

A short summary of approaching house calls in Ontario and tips to consider.





This is a free, independent drug safety website to help weigh the benefits of any medication against its potential dangers.



Mental Health, Addictions and Pain

Ontario College of Family Physicians

Medical Mentoring for Addictions and Pain

This program supports physicians with relevant expertise to mentor family physicians interested in chronic pain and addictions. The Collaborative Mentoring Networks are certified under Mainpro+.


Collaborative Mental Health Network

The Collaborative Mental Health Network links family physicians from across the province with a GP psychotherapist and psychiatrist mentor.


Centre for Effective Practice

Management of Chronic Non-Cancer Pain Tool

This tool will help family physicians and primary care nurse practitioners to develop and implement a management plan for adult patients living with CNCP.


Centre for Effective Practice

Supporting Material: EMR Tool

This tool incorporates the clinical Centre for Effective Practice Management of Chronic Non-Cancer Pain Tool. It is currently available for TELUS PS Suite and an OSCAR EMR version is in development. The tool is divided into the following sections:

  • Baseline Assessment
  • Ongoing Assessment
  • Non-Pharmacological Therapy
  • Non-Opioid Medications
  • Opioid Medications
  • Intervention Management and Referral

This approach allows clinicians to conduct a complete assessment and provide a tailored management plan that incorporates the patient’s goals, while adhering to current best practices in providing improved CNCP management overall.


Health Quality Ontario

Quality Improvement: Partnered Supports for Helping Patients Manage Pain

This collaboration among partner organizations across the health system is a coordinated program of supports to help clinicians manage their patients’ pain, including the appropriate use of opioids. This link summarizes what is or will soon be available through this program.



Pediatric Medical Homes

American Academy of Pediatrics / National Center for Medical Home Implementation

Tools & Resources

A number of tools and resources are offered to assist families, practices and others with pediatric medical home implementation and related efforts to enhance collaboration between professionals and families.


Fostering Partnership and Teamwork in the Pediatric Medical Home: A “How-To” Video Series

The videos show pediatric practices how to create efficiency through team huddles, build a stronger medical home through family advisory groups, and enhance collaboration with families through care partnership support. The videos provide strategies, benefits and guidance on implementation in a practice setting.



Health Promotion

Public Health Ontario

Health Promotion Audio Presentations

This collection of short (under 10 minute), introductory-level audio presentations are designed to build capacity for evidence-informed health promotion practice. Topics covered include planning, evaluation, health communication, policy development in general and alcohol policy development in particular.