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Patient's Medical Home - Outstanding Family Practice Award (PMH)

As a chapter of the College of Family Physicians of Canada, the ACFP supports the vision of a Patient’s Medical Home (PMH), a model of care that puts the needs of patients and their communities at the centre of care.

The PMH is where patients can present and discuss their personal and family health concerns and receive the full spectrum of expert care. The PMH team is developed to meet the needs of its own patient community and, depending on those needs, may involve nurses, other specialists, and other health care providers, who work together in one centre or virtually. The PMH supports the relationships between patients and family physicians and other health care providers as they develop and strengthen over time, enabling the best possible health outcomes for each person, practice population, and the community being served.

Candidates are nominated by their peers, members of the public, or are self-nominated.
Submission Deadline: April 1, 2025
Download Nomination Form

Awards Criteria

  • The nominee has been in practice for a minimum of two years (i.e., the family practice or clinic has been in operation for at least two years)
  • Candidates may be recognized for their exemplary implementation of the PMH Pillars
  • Candidates may be recognized for demonstrating their adaptative, innovative, resourcefulness, and resiliency in pursuit of implementing one or more of the PMH Pillars
  • The nominee has NOT received this award previously (to the best of your knowledge)


Note: Clinics, where current members of the ACFP Board and Member Engagement and Recognition Committee practise, are still eligible for the award; however, during the review process the said Committee member will abstain from the voting and review preference.

Need Support?

Email the ACFP at ACFPAwards@acfp.ca.

→ Riverbend Medical Clinic

2024 Award Recipients

The ACFP is proud to celebrate all physicians, residents, students, and clinics who demonstrate excellence in family practice. 

 To learn more about this year’s amazing list of recipients as well as previous ACFP Award winners, visit our Award Recipients page through the button below.

Award Recipients

The biggest challenge or success we have had in adopting Patient’s Medical Home (PMH) in our clinic: The biggest challenge relates to turn-style medicine, where patients visits are short and our ability to treat comprehensive issues requires a lot more visits over time. We try to counter this by adopting a team-based approach, focusing on the patient-doctor relationship and referrals in/outside of our clinic, so the family physician doesn’t have to manage too many things on their own. Relatedly, our clinic is part of a PCN but many of the services require that patients travel, and transportation/cost becomes an issue, just to get there – even if the service is covered. If more PCN services were available within the community we’re in, or even better, in house, engagement and outcomes would likely also be better, with respect to the PMH model of care. Our biggest success relates to the synergy we have, where front, middle, and back end (e.g., MOA, manager, physician, owner) are regularly meeting, discussing strategies and systematic processes that can be implemented to maximize positive experiences for patients, as well as job satisfaction and well-being of clinic staff. This promotes return-to-care and follow up, which facilitates better engagement and health outcomes.

What advice would you give to other clinics? Building strong bonds between patients and health care staff is crucial for the overall effectiveness of a clinic. When a good relationship is established, it creates a foundation of trust, communication and mutual respect that significantly enhances the patient experience and improves outcomes. A well-bonded team of health care professionals fosters a collaborative and supportive work environment. When staff members work harmoniously, it reflects in their interactions with patients. Consistent and cohesive care, driven by shared understanding of each patient’s needs and preferences, ensures that treatments are more effective and patient-centered. This teamwork also boosts staff morale and job satisfaction, reducing burnout and turnover rates. Using the Job Demands Resources Theory and the Self-Determination Theory, our Medical Director seeks to better understand, assess, implement and optimize workflows and processes while keeping the human drivers of engagement, performance and wellness front and centre.

One thing that you will be surprised to learn about our clinic: Dr. Neufeld, our Medical Director, typically sees more than 150 patients per week and yet makes time for teaching medical students and residents, and conducts patient-oriented research. Over the past 2 years, we’ve had successfully had over 15 learners come through and work with him and our staff, and we have published over six peer-reviewed journal articles pertaining to aspects of patient motivation, health, and well-being. An integral part of what allows Dr. Neufeld to engage in these ‘extras’ has been the staff involvement. 

Riverbend Clinic

2024 Patient's Medical Home- Outstanding Family Practice Award

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