TRAINING

The Patient-centered, Family-focused and Community-

oriented (PFC) Matrix: A Toolkit for Biopsychosocial
Approach in Primary Care

Zorayda E. Leopando, MD, MPH, FPAFP1; Leilanie A. Nicodemus, MD, FPAFP1 ; Anna Guia O. Limpoco, MD, FPAFP1,
and Ma. Elinore A. Concha, MD, FPAFP2

Biopsychosocial (BPS) approach to care is essential in family practice. Teaching this approach in family medicine is usually
highlighted in family case presentations and counseling sessions. Little is done in showing how the biopsychosocial
approach can be used in the day to day family practice. This article discusses the development of a learning tool called
the PFC matrix which is a patient-centered, family-focused and community-oriented approach to care for individual
patients and their families.
The patient-centered care utilizes understanding of the interplay of biomedical psychosocial factors disease in order to
implement management that is tailor-fitted to the needs and values of the patient. The family-focused component of the
matrix utilizes family assessment to generate assumptions on how the family dynamics affect or facilitate the prescribed
management of the patient’s disease. Lastly, the community-oriented component enables the family physician to use social
determinants of health and health systems as a lens to understand how larger systems support or hinder the provision of care.
Through the use of this matrix, the family physician is able to manage the patient in a holistic manner by recognizing patient
needs, creating an enabling family support environment and helping the patient and family navigate various community
resources. This results not only in optimal health for the patient but impacts to create a more responsive health system. In
the future, further documentation of the use of the PFC matrix particularly in primary care in the light of universal health
care and how it impacts on outcomes and how it connects patients and families at the correct tiers of the health system.

Keywords: Biopsychosocial approach, family medicine, patient-centered care, family-focused care, community-oriented care

INTRODUCTION impact of the disease and should be considered when planning

delivery of care.
Biopsychosocial (BPS) approach to care is one of the methods Several teaching methods were done to integrate BPS
to promote patient-centeredness. It is a perspective that patient’s in medical interviewing in medical schools and primary care
concern cannot be taken in isolation but rather, both biomedical physicians’ training but it is always related to counselling that
and psychosocial aspects of patient’s predicament may affect the requires more intensive and laborious course offerings.1 In the
United States, biopsychosocial model has been integrated in
the medical curriculum through variety of teaching methods
_______________ like lectures, small group discussions, clinical encounters and
1
From the Department of Family and Community Medicine, College of inter-professional education.2 These methods still have to be
Medicine, University of the Philippines Manila and investigated for their effectiveness in terms of improvement
2
Department of Family and Community Medicine, Southern Philippines of patient outcomes. In South Africa, teaching biopsychosocial
Medical Center, Davao City competence was longitudinally implemented to enhance primary

26 THE FILIPINO FAMILY PHYSICIAN

health care approach.3 The course content includes culture, psyche Fakultas Kedokteran Universitas Andalas Indonesia.5 The activity
and illness, health promotion and evidence-based practice. was an integration session of the 1-week course on family
Teaching strategies included portfolio development of patient medicine principles & concepts and practice. The participants
mini-ethnographies from where sample cases are discussed by were able to identify key features in the case study that reflected
preceptors using a structured portfolio interview method. Direct concepts learned pertaining to patient-centered care, family-
application of concepts to patient care, improved communication oriented care and community-oriented care. Significant insights
skills, and critical thinking skills were the positive educational to this experience among the participants were: 1) application of
values identified using this method. concepts to actual patient care; 2) understanding of family case
Patient case analysis using the Patient-centered, Family- reports as method of teaching; 3) need for deeper learning on
focused and Community-oriented (PFC) Matrix is a novel teaching social contexts of patients.
strategy that was designed to simplify the learning of process In 2014, the first Textbook of Family Medicine of the
of integrating the biopsychosocial information gathered in the Philippine Academy of Family Physicians (PAFP) was published
medical interview to come up with holistic management of where the PFC matrix was introduced to concretize the concepts
the patient. This cognitive framework aims to enable learners and principles of family medicine as applied in family medicine
to develop the competence of providing comprehensive care practice.6 On the same year, the Department of Health Family
for every patient encounter in different settings, particularly and Community Medicine Residency Training (DOH FMRTP)
in primary care. The use of the matrix was implemented in the faculty development workshop included the PFC matrix as
educational programs of both undergraduate medical education, teaching tool in residency training aimed to provide trainees
residency training and postgraduate degree of the University deeper understanding of the biopsychosocial approach to care
of the Philippines College of Medicine and Philippine General and consequently develop the competence of integrated and
Hospital respectively spearheaded by the Department of Family comprehensive care of patients managed in different settings,
and Community Medicine. This short article presents the particularly in the rural areas.7
historical context of the PFC matrix, its components and how it In 2016, Family Health Unit (FHU) of the DFCM UP-PGH
can be applied to analyze a case. was conceptualized and established by Nicodemus and Medina
to provide a venue for family-oriented services in order for
Historical Background and Developmental Milestones of the residents to apply their knowledge on family medicine
the Matrix concepts and principles in patient care.8 The PFC matrix was the
method used on teaching trainees biopsychosocial perspectives
In 2000, regular “brown-bag” case discussions were in managing chronic management of geriatric patients with
conducted with clinical clerks and residents in training at the knee osteoarthritis (Osteoarthritis Multi-disciplinary Clinic),
Department of Family and Community Medicine University of adolescents with learning and developmental disabilities
the Philippines-Philippine General Hospital (DFCM UP-PGH) (Transition Care), psychosocial support for families with
and introduced an organized method of analyzing selected deliberating and chronic diseases. The matrix was revised to
patient cases seen at the OPD of the Department using a provide in-depth case discussions as well as organizing the
biopsychosocial lens. The matrix followed the Subjective- family-oriented charts. On the same year, the Integrated Clinical
Objective-Assessment-Plan (SOAP) commonly used as Clerkship in Family Medicine 2-week rotation included end-
freestyle-patient charting method. These case discussions, of-rotation case analysis using the PFC matrix. Evaluation tool
though not documented, enabled different types of learners, was developed to evaluate the ability of the medical students
including postgraduate students, to develop a lens for an to gather biomedical data and relevant psychosocial issues
integrated biopsychosocial case analysis. This was the birth attendant to patient’s medical conditions to include enabling
of the PFC Matrix that took the centerstage of teaching the factors and/or barriers in the family dynamics and community
biopsychososial approach (BPS). resources for the delivery of care.9
In 2003, the same matrix mentioned previously was used In 2017, the PFC matrix was introduced as part of the faculty
to analyse a published case study of a family with a member development topics of the DFCM UP-PGH. The series of workshops
afflicted with HIV.4 This was the first in many papers that will elicited ideas on the enhancement of the contents of matrix to
use the matrix to dissect both clinical and family cases. account for expansion of its use in teaching and learning of family
In 2013, the PFC matrix was used in teaching biopsychosocial and community medicine on both the undergraduate courses and
approach to the faculty undergoing faculty development residency training. Relevant changes include the use of the social
program in Family-oriented Medical Education (FOME) of determinants of health and WHO components health systems as

VOL. 57 NO. 1 JANUARY - JUNE, 2019 27

perspective to understand the community-oriented care. This These are the same information are included in the matrix (Table
current form is used in this article. 1) with further elucidation of psychosocial issues attendant to
In 2018, the PFC matrix has been cascaded to the different the illness aside from accurate recording of history taking and
family and community medicine trainers in Luzon, Visayas and physical examination to come up with the valid biomedical and
Mindanao. The feedback was the session was informative and psychosocial diagnoses.
the matrix can easily be adapted and applied. The clamor though Consequently, the understanding and consideration of the
is more modules on the community aspects of the matrix. This is patient’s whole person will enable the physician tailor-fit disease
similar to the experience of Indonesia. management, that is the most essential part of patient-centered
To date, the matrix has been used in several ways: 1) teaching care.12-13 Such approach includes identification and addressing
method to enhance understanding of the biopsychosocial misperceptions of patients about their health through health
approach in the undergraduate courses; 2) framework integrated education and counseling. A psycho-educational method called
biopsychosocial analysis of clinical cases in different settings in Catharsis-Education-Action (CEA) technique was developed
residency training; 3) biopsychosocial patient chart recording based on the client-centered approach. This technique aims
for family health units or family health care programs; and to address identified barriers from emotional misperception
4) as curriculum framework for the practice-based family and of patients to enable positive behaviour and action towards
community medicine training program. personal health and wellness.14 Other techniques toward health
promotion and prevention such as motivational counselling for
Theoretical Framework and Components of the PFC Matrix smoking cessation, dietary and lifestyle change are also part of
the interventions without discounting the implementation of
A. Patient-centered Care evidence-based standards of care according the all levels of care
utilizing clinical practice guidelines to properly addressing the
Patient-centeredness is core to family practice. It means biomedical disease.
having the patient at the center of consultation process by
creating a safe environment in which the patient will be able B. Family-focused Care
to express accurately the disease and illness experience. Studies
have shown that this type of doctor-patient relationship is Heredofamilial diseases are always included from the
correlated with good patient outcomes. The systematic review time the history-taking during physical diagnosis is taught. The
done by Stewart in 1995 showed that good communication introduction of Family Medicine residency training in 1974, led
and patient education in seven (7) RCTs included in the review to the realization that the family plays a bigger role in health
demonstrated improved physical health, level of function, blood and disease. In addition to genetics, common environmental
pressure and blood glucose level.10 The processes pertaining to exposures and shared health behaviors and resources allow the
patient-centeredness include exploring perceptions of patients family to contribute to its individual members health.15 Thus,
about the illness in the history-taking and providing information the Family Health Care Program became a standard feature of
and explanatory statements regarding the disease by physicians.11 the program with residents taking care of index patients and

Table 1. Patient-centered matrix

Components Patient-centered

etc appropriate to address the identified issues.

28 THE FILIPINO FAMILY PHYSICIAN

extending the care to their families. Indeed, the family is our 6) the family lifeline which connects the clinical problems
greatest ally in health care.16 A family member is present in with highlights in the life of the patient or family;
the consultation room, in the wards or hospital room when
admitted, will help carry out plan of management when patient Management of problems which highlight the focus on
is sent home. For example, lifestyle modification needs family family shall include health education for the members of the
cooperation and out-of pocket expense is borne by the family. family, primary counseling, family meeting, family counseling,
In 1989, the Family Health Development Workshop was and capacity building for the caregiver using the same techniques
conducted to learn more about the principles and concepts in cited elsewhere. These are included in the following component
Family Medicine. This gave rise to Orientation Course in Family of the matrix. (Table 2)
Medicine which was required for all members of the Philippine
Academy of Family Physicians. The family as unit of care, family C. Community-oriented Care
structure and function, family psychodynamics, family as a
system, impact of illness in the family were topics discussed Community oriented primary care (COPC) is an integration of
in the course. These are very important in enhancing the clinical science and public health. It is a systematic approach that
understanding the families of our patients.17 a primary care physician should use in the analysis of individual
Working with families brings us to higher level of issues. and population-based care.19 COPC is an approach to health care
Hennen and Rice discussed the participation of the family in based on the principles derived from epidemiology, primary care,
all levels of prevention. This was further elucidated through preventive medicine and health promotion.20
health encounters and issues at the various stages of the family COPC systematically puts together the elements of primary
life cycle.15 The following tools for family assessment were health care and community medicine in a coordinated manner.21
introduced:18 To this day, this union is still a feature on primary health care of
1) the family genogram which included the family tree, the Astana Declaration. That is, strengthening health systems by
heredofamilial diseases, who among the members are investing in primary health care (PHC).22
living together In the context of the PFC matrix, community orientedness
2) the family map which shows relationship among borrows from principles of the COPC. Community orientedness
members; uses the social determinants of health (SDH) and the World
3) the family Adaptation, Partnership, Growth, Affection Health Organization (WHO) building blocks as lens in the
and Resolve (Family APGAR) which measures the level analysis of the health system relevant to the presented medical
of satisfaction of members in 5 functions of the family; and psychosocial issues of the individual patient and family as
4) Family circle where the size and distance of circles can illustrated in the table. A family physician should be able to
give clue on degree of closeness of members and can be provide assessment of the general socio-cultural determinants,
used even for children living and working conditions, environment and sanitation that
5) family Social, Cultural, Religious, Economic, Education may affect the patient’s condition. This can be facilitated by using
and Medical (Family SCREEM) which when described the ECOMAP and SCREEM. (Table 3 for the Community-oriented
positively can be strengths or resources to solve the Matrix)
problems and when discussed negatively can be The building blocks of health system such as service delivery,
weaknesses or possible cause of the problems; health workforce, health information system, access to essential

Table 2. Family-focused matrix

Components Patient-centered

Resonance, Ecological context, Development - STFRED)

VOL. 57 NO. 1 JANUARY - JUNE, 2019 29

medicines, financing and leadership/governance within the the illness diagnosis of the family’s breadwinner, the physician
locality of the patient affecting the existing medical condition did not only help the patient cope with his disease but was able to
are analyzed to provide the bases for summary statements help the family address issues that arose due to it. The physician
or conclusions that can be both enabling and/or barrier to the was also able to link the patient with community resources that
provision of care. Patient and/or families understanding of helped him and his family cope with his condition.
their ecological and political environment however limits this
component of the PFC matrix.
Features of COPC like continuity of care, suitable arrangements CONCLUSION
for consultative services, specialist care and hospitalization
necessitate competencies to navigate the resources, address Espousing the biopsychosocial approach to care in the
barriers and hazards that may affect the care for individuals and light of increasing fragmentation of the system is essential in
families in the community.21 the achievement of universal health care. A physician using an
Short-term and long-term solutions to overcome the integrative lens in the care of a patient by mobilizing the family
barriers or facilitate the enabling effects of the identified and helping them navigate necessary community resources can
social determinants and components of the building blocks help in care coordination, lesser duplication and maximization of
of health systems are dependent on the existing health resources.
programs implemented by the local government that can be The PFC matrix provides trainees from the medical clerkship
tapped. Physicians’ knowledge on patient’s rights, health laws, level through residency and eventual clinical practice, a simple
patient support groups and government and non-government and practical tool to look at the patient’s medical problem in the
health programs is also an advantage so as to enable referral, context of the family and community. In this way, while centering
collaboration and networking. on the patient’s condition and management, they see the bigger
context of care for the patient in terms of his/her family and
Sample Use of the PFC Matrix community. This systems thinking would hopefully pave the
way for the generalist physicians and family and community
The case study of a male overseas Filipino worker who is the medicine practitioners in the frontline to better embrace the
family’s breadwinner suffering from HIV AIDs and its concurrent concept of linked health care delivery units in the different tiers
impact on the patient, family and community is summarized in of the service delivery network. Thereby, better contributing to
the PFC matrix below. (Table 4) the realization of universal health care.
The reader is referred to the article of Valencia, et al.5 for full Moving forward, it is necessary to document the experiences
details of the case. It can be accessed through this link: http:// in using the PFC matrix in various teaching learning activities
www.academia.edu/6931642/Impact_of_HIV_AIDS_on_an_ such as bedside rounds, clinical preceptorships, case discussions
overseas_Filipino_worker_and_his_family and get mentor and learner feedback of its effectiveness as
At one glance, the physician was able to see the complexity a teaching tool. It is also imperative to conduct researches on
of the case not merely from the biomedical perspective but how using the PFC matrix can help improve patient outcomes,
incorporating the psychosocial realm important in the systems family participation in care and optimal utilization of community
approach. In seeing the multifaceted problems that arose from resources to aid the patient on the road to wellness.

Table 3. Community oriented matrix

Components Patient-centered

and psychosocial issues of the case

30 THE FILIPINO FAMILY PHYSICIAN

Table 4. Application of the PFC matrix given a patient’s case

Components Patient-centered Family-focused Community-oriented

Data Biomedical history Family genogram

dyspnea, anorexia and members

deteriorating health APGAR

recurrence of symptoms resolve (screen family dysfunctions and measures

the patient’s level of satisfaction about family
Psychosocial Issues relationships
Family Map
experienced job
dissatisfaction and generations, presence of conflicts and alliances,
maltreatment sought involvement among family members
comfort through SCREEM
promiscuous relationships
resources that may assess family as to its capacity
ones due to the HIV to participate in provision of health care or can be
pathology for the condition of the patient
Family lifeline

and how it was handled

Analysis Biomedical history

test, who is presenting

with progressive dyspnea identified
and deteriorating health
with prior history of pTB resources
Psychosocial issue

proper treatment

Diagnosis/
Conclusion/ immunocompromised prevalence
Assumptions state; T/C HIV with and feeling of loneliness
opportunistic infection
the workplace
condition

Management/
Interventions opportunistic infection, existing policies on HIV AIDS
co morbidities and co-
infections opportunistic

HIV and co-morbidities

(Catharsis-education-
action) to address the
identified emotionally
critical misperceptions
(ECMs), provide emotional
support and alleviate fear
and anxiety

VOL. 57 NO. 1 JANUARY - JUNE, 2019 31

Ethical Considerations 9. Samonte MS and Nicodemus LA. FCH 250.1 Integrated Clinical
Clerkship in Family Medicine Instructional Manual. Department
of Family and Community Medicine Philippine General Hospital.
The review was registered in UP Manila Research Grants
(unpublished data-on file) 2016.
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processing and management were in accordance with the outcomes: a review. CMAJ: Canadian Med Assoc J 1995; 152(9): 1423.
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