How health homes are changing primary health care in Nova Scotia

“This is the future of primary care in Nova Scotia.” 
- Dr. Maria Alexiadis, Senior Medical Director, Primary Health Care & Chronic Disease Management, Nova Scotia Health
 

If you’ve noticed the term “health home” appearing in local news or on new clinic signs across Nova Scotia, you might be wondering what it means. The concept isn’t new; Nova Scotia has been working toward this model of care for years.
 

Health homes build on the foundation laid by collaborative family practice teams, which brought together family doctors, nurse practitioners, and other health professionals to care for patients under one roof. While the collaborative model focused on who worked in a clinic, the health home model focuses on how care is delivered and co-ordinated so patients receive the right care, at the right time, from the right provider.
 

The health home model is part of a broader shift across Canada and beyond toward more team-based, patient-centred primary care. It builds on the College of Family Physicians of Canada’s Patient Medical Home model, which has guided primary care transformation across the country. In recent years, other provinces like Ontario have begun introducing similar models, supported by leaders like former federal health minister Dr. Jane Philpott, to strengthen access and co-ordination of care. While interest in this approach continues to grow nationally, Nova Scotia has been steadily putting its foundations in place for years, strengthening teams, improving collaboration, and adapting the model to meet the needs of local communities.
 

Today, more than a hundred clinics across Nova Scotia Health operate as health homes, with new clinics opening and existing teams adopting the model every year. 
 

Additionally, there are more than 150 primary care practices across the province that are not connected to Nova Scotia Health. All these practices provide incredible primary care to Nova Scotians, and some may also follow a health home model of care. Each shares the goal of providing more connected, team-based primary care for their communities.
 

“A health home isn’t a new kind of building,” explained Dr. Maria Alexiadis, senior medical director with the Primary Health Care and Chronic Disease Management Network. “It’s a way of delivering care that any primary health care team can adopt, no matter where they work or how long they’ve been providing care. It focuses on care that is patient-centred, comprehensive, and continuous, supported by a team of health care providers who work together to meet their patients’ needs.”
 

Jennifer Kelday, health services manager in Nova Scotia Health’s Western Zone, shares her experience meeting with teams to explore what the model looks like in practice.

“We’ve spent the past several years building strong teams and improving access to care,” said Kelday. “Now, in addition to that ongoing work, we’re entering a new, exciting phase where we can focus on optimizing how our health homes work.”
 

For Kelday, that means supporting teams in recognizing how far they’ve come and helping them take the next step in a way that fits their unique circumstances. Each clinic is different, with its own mix of providers, patient needs, and community context, so progress looks different from place to place. “Our goal is to provide the tools, time, and support to keep building on what’s working for each team.”
 

One of those tools is the Health Home Assessment, a team-based reflection process that helps clinics identify strengths, explore opportunities, and plan next steps together. As teams build on their progress, they focus on strengthening co-ordination and continuity of care. The tangible goals of this work include ensuring patients can see their care team when they need to, receive follow-up from someone who knows their story, and experience smooth transitions when connecting with other services such as mental health support, pharmacy care, or home care in the broader “health neighbourhood”. Behind the scenes, teams refine clinic flow, share information, and use data to plan care proactively so the care feels consistent and patient-centred.
 

“The best part of the assessment was having dedicated time and space to step back from the day-to-day and really look at how we work as a team,” said AnnDelynn MacDougall, a social worker formerly with the Sydney Primary Care Medical Clinic. “It helped us see where we could strengthen or improve our processes. Being in one room and going through the questions together allowed us to hear each other’s perspectives and gain a better understanding of our roles. It allowed us to ask questions and discuss our responses as a team in real time.”
 

“The assessment is a great way for teams to have input,” said Kelday. “Everyone sees things a little differently depending on their role, and those conversations help clarify responsibilities, improve communication, and give everyone a voice at the table. The assessment helps us ensure they have the resources and structure to keep that momentum going.”
 

Once a team completes the assessment, they review the results together and create an action plan. “After that, we talk about what’s going well and where more support might be helpful,” Kelday explained. “Then we build a plan together and set up regular check-ins to review progress. It’s about keeping that continuous improvement cycle alive within the health home.”
 

Alexiadis added that the model gives teams a shared way to look at their work. “When roles are clear and communication is strong, teams can co-ordinate more smoothly across the clinic and with partners in the community,” she said. “For patients, this means care that feels more coordinated and consistent, no matter where they receive it.”
 

Across the province, health homes continue to evolve as teams strengthen communication and build on the foundations already in place, helping to shape a primary healthcare system that’s more responsive to the needs of Nova Scotians.
 

“This is the future for primary care in Nova Scotia,” said Alexiadis. “It’s about refining how we work together so we can deliver the best care possible.”
 

To learn more about health homes across our province, visit 

https://www.nshealth.ca/health-homes.