Comprehensive primary care

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1 Comprehensive primary care What Patient Centred Medical Home models mean for Australian primary health care Northern Queensland Primary Health Network November 2017

2 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care Published by Northern Queensland Primary Health Network (NQPHN), September 2017 NQPHN would like to thank and acknowledge the following organisations and publications as reference sources for this document: Western Australia Primary Health Alliance, WentWest, North Western Melbourne PHN, Transforming Primary Care: The Patient Centred Medical Home in Western Sydney, and The Health Care Home: What it Means for Australian Primary Health Care. For more information, contact: p: 1300 PRIMARY ( ) e: w: nqpcmh.com.au w: primaryhealth.com.au Northern Queensland Primary Health Network respectfully acknowledges the Traditional and Historical Owners, past and present, within the lands in which we work. 2

3 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care Contents About Northern Queensland Primary Health Network 4 A case for change 5 The Patient Centred Medical Home 6 The 10 building blocks 7 Why the medical home works: A framework 8 Measuring outcomes 9 Defining the Quadruple Aim 9 What can we do? 10 Further reading 11 3

4 About Northern Queensland Primary Health Network OUR VISION North Queenslanders live happier, healthier, longer lives. OUR PURPOSE To ensure people of Northern Queensland access primary health care services that respond to their individual and community needs, and are relevant to their culture, informed by evidence, and delivered by an appropriately skilled, well-integrated workforce. Primary Health Networks (PHNs) have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients particularly those at risk of poor health outcomes and improving coordination of care to ensure patients receive the right care, in the right place, at the right time. The Better Outcomes for People with Chronic and Complex Health Conditions: Report to Government on the Findings of the Primary Health Care Advisory Group (the PHCAG report), provided to the Australian government in December 2015, sets out the blueprint for primary care system reform. The Australian Government responded to the report with the announcement of the Healthier Medicare package in March The PHCAG report identified high rates of chronic disease and associated high use of medical services as being a key challenge for the system. In addition, the report highlighted the fragmentation of care coordination between providers of healthcare services. The report recommended a set of reforms aimed at transforming the health system to better meet the needs of people with chronic and complex conditions. Central to the proposed reform is the formalisation of the relationship between the patient with a chronic and complex condition and their health care home (PHCAG,2016). The Patient Centred Medical Home (PCMH) model on which the Health Care Home (HCH) approach is based promotes care that is patient-centred, physician guided, cost-efficient, and aimed at achieving agreed long-term health goals. The model introduces the concept of accountable care, where a single provider or group of providers, usually a general practitioner (GP), becomes the central coordination point for a patient, and accepts a level of accountability for that patient s outcomes. In this model, best practice care is provided usually by a multidisciplinary care team and coordination is enhanced through the use of systems, tools, and coordination workers. Northern Queensland Primary Health Network (NQPHN) is funded to support general practice teams to increase their readiness to implement the HCH model of care. A PCMH is an existing general practice, or Aboriginal Medical Service (AMS), that commits to a systematic approach to chronic disease management in primary care, which supports accountability for ongoing, high-quality, patient care. The NQPHN PCMH readiness program supports the HCH model of care that forms a part of the Australian health reform agenda. 4

5 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care A case for change Key challenges currently facing the Australian health care system are the increasing number of people with chronic and complex conditions and the increasing costs of providing health care to this cohort. The Better Outcomes for People with Chronic and Complex Health Conditions: Report to Government on the Findings of the Primary Health Care Advisory Group identified that 35 per cent of Australians have a chronic condition. The Australian Institute for Health and Welfare (AIHW) reported in 2015 that 20 per cent of Australians had two or more chronic conditions. AIWH 2016 report associations between chronic disease and risks factors identifies that modification of risk factors can directly reduce the number of people that go on to have a complex and chronic disease. The above reports examined these challenges and possible solutions. These solution suggest that primary health care organisations and general practices working in partnership to provide a coordinated, multidisciplinary, patient-centred approach to primary healthcare could proactively improve quality of care and access, minimise waste, and maximise appropriate use of resources available within the healthcare system. CONCEPTS FOR THE FUTURE OF PRIMARY CARE TODAY FUTURE Treating sickness/episodic Managing populations Fragmented care Collaborative care Specialty driven Primary care driven Isolated patient files Integrated electronic records Utilisation management Evidence-based medicine Fee for service Shared risk/reward Payment for volume Payment for value Adversarial payer-provider relations Cooperative payer-provider relations Everyone for themselves Joint contracting Bodenheimer, T et al Annals of Family Medicine Vol 12 Number 2 march/april

6 The Patient Centred Medical Home The principles of a Patient Centred Medical Home (PCMH) were developed in the USA in anticipation of the very same challenges we are facing in Australia today. These principles are universal and also reflect longstanding principles of quality general practice by colleges in Australia, the UK, and elsewhere. Many of these elements exist in our health system today. Northern Queensland Primary Health Network s (NQPHN s) role is to comprehensively strengthen these principles and elements in close partnership with general practice, other primary care providers, and the broader health system. The general practice of the future will continue to see its primary purpose as the provision of general practitioner-led, patient-centred, continuing, comprehensive, co-ordinated, whole person care to individuals and families in their communities. (A Quality General Practice of the Future, RACGP 2012). FUTURE DEFINITION Patient-centred Supports patients and families to manage and organise their care and participate as fully informed partners in health system transformation at the practice, community, and policy levels. Comprehensive A team of care providers is wholly acountable for patient s physical and mental health care needs includes prevention and wellness, acute care and chronic care. Coordinated Ensures care is organised across all elements of broader health care system, including specialty care, hospitals, home health care, community services and supports, and public health. Accessible Delivers consumer-friendly services with shorter wait times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations. Committed to quality and safety Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions. 6

7 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care The 10 building blocks The 10 Building Blocks of High-Performing Care is a conceptual model described by Bodenheimer et al. It identifies and describes the essential elements of primary care that facilitate exemplary performance. NQPHN, working closely with its general practice leaders and leveraging off international learnings, has used this as a framework to plan and implement its approach to PCMH. Block 1: Engaged leadership Leaders at all levels in the practice who facilitate change. Leaders work towards the Quadruple Aim enhanced patient experience, improving population health, reducing health expenditure, and improved work life balance of health care providers. Block 2: Data-driven improvement Data systems that track clinical, operational, and patients experience. Meaningful use of this data to inform clinical, operational, and patient experience quality improvement. Block 3: Patient empanelment Linking each patient to a care team and primary GP. Block 4: Team-based care Practice teams share the care of a patient. Responsibilities not tasks are reallocated within the team and all team members function at the top of their scope of practice. This increases capacity and access. Block 5: Patient-team partnership Patients and their families/carers are regarded as an important part of the care team. Patients are not told what to do but are engaged in shared decision making and the development of personal goals. Health coaching and self-management is incorporated into everyday care. Block 6: Population management This involves reviewing whole of practice clinical data and developing resources and system to provide appropriate care as required. Block 8: Prompt access to care Access is closely linked to patient satisfaction, and by default patient empanelment. Prompt access to the primary GP is also linked to improved continuity of care, and therefore improved patient outcomes. Block 9: Comprehensiveness and care coordination The capability of the practice to provide most of what the patient requires (one stop shop) or the ability of the practice to coordinate access to the services that the patient requires. Block 10: Quality general practice of the future High performing primary care practice that accesses and utilises bundled payments to provide patient focused, goal outcome care. 8 Prompt access to care 10 Quality general practice of the future 9 Comprehensiveness and care coordination Block 7: Continuity of care Continuity of care is associated with improved preventative and chronic care, greater patient and clinician experience, and lower costs. To achieve continuity of care a patient needs to link to a primary GP who then manages their case. 5 Patient-team partnership 6 Population management 7 Continuity of care Engaged leadership Data-driven improvement Patient empanelment Team-based care 7

8 Why the medical home works: a framework FEATURE DEFINITION SAMPLE STRATEGIES POTENTIAL IMPACTS Patientcentred Comprehensive Supports patients and families to manage and organise their care and participate as fully informed partners in health system transformation at the practice, community, and policy levels. A team of care providers is wholly acountable for patient s physical and mental health care needs includes prevention and wellness, acute care and chronic care. dedicated staff help patients navigate system and create care plans focus on strong, trusting relationships with GPs and care team, open communication about decisions and health status compassionate and culturally sensitive care. dedicated staff help patients navigate system and create care plans focus on strong, trusting relationships with GPs and care team, open communication about decisions and health status compassionate and culturally sensitive care. Patients are more likely to seek the right care, in the right place, at the right time. Patients are less likely to seek care from the emergency department or hospital, and delay or leave conditions untreated. Providers are less likely to order duplicate tests, labs, or procedures. Coordinated Ensures care is organised across all elements of broader health care system, including specialty care, hospitals, home health care, community services and supports, and public health. care is documented and communicated effectively across providers and institutaions, including patients, primary care, specialists, hospitals, home health, etc. communication and connectedness is enhanced by health information technology. Better management of chronic diseases and other illnesses improves health outcomes. Focus on wellness and prevention reduces incidence/severity of chronic disease and illness. Accessible Delivers consumerfriendly services with shorter wait times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations. more efficient appointment systems offer same-day or 24/7 access to care team use of e-communications and telemedicine provide alternatives for face-toface visits and allow for after hours care. Costs savings result from: appropriate use of medicine fewer avoidable ED visits, hospitalisations, and readmissions. Committed to quality and safety Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions. EHRs, clinical decision support, medication management improve treatment and diagnosis clinicians/staff monitor quality improvement goals and use data tp track populations and their quality and cost outcomes. Supports patients and families to manage and organise their care and participate as fully informed partners in health system transformation at the practice, comunity, and policy levels. Patient Centred Primary Care Collaboratives (2013) 8

9 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care Measuring outcomes Measuring outcomes from Northern Queensland Primary Health Network s (NQPHN s) investment in the development of the Patient Centred Medical Home (PCMH) model within general practice is an important consideration. THE QUADRUPLE AIM The impact of both NQPHNs traditional approach to supporting general practice and also their responsibility as a Primary Health Nework (PHN) being broader than general practice alone, needs to be considered. In the context of the NQPHN footprint, the Quadruple Aim Framework has been adopted, founded in the work by the Institute for Healthcare Improvement. Enhancing patient experience Reducing health expenditure Improving population health Improving work-life balance of health care providers Defining the Quadruple Aim Patient experience of care reduced waiting times improved access patient and family needs met. Improved provider satisfaction increased clinician and staff satisfaction teamwork leadership quality improvement culture. Quality and population health improved health outcomes equity of access reduced disease burden Sustainable cost cost reduction in service delivery reduced avoidable/unnecessary hospital admissions return on innovation costs invested ratio of funding for primary acute care. 9

10 What can we do? Patient Centred Medical Home (PCMH)-based models of care have broad support from policy makers (refer the Federal Government s Healthier Medicare package) and growing support from providers led by the Royal Australian College of General Practitioners (RACGP). While the PCMH-based models of care in Australia are still being tested, it is imperative that Primary Health Networks (PHNs) across Australia engage in the discussion, development, and application of evidence. Northern Queensland Primary Health Network (NQPHN) is committed to developing and enhancing the PCMH model within the NQPHN context and implementing the PCMH model through: practice engagement and support investing to build the capacity of the primary healthcare sector promoting patient-centred models and a health literacy-based approach to care promoting technology-based solutions including My Health Record, HealthPathways, telehealth, and GP Viewer the collection, collation, and meaningful use of de-identified clinical data. NQPHN is well positioned to provide support in general practice to establish the foundations upon which the PCMH model of care can be implemented across the NQPHN footprint. The effectiveness of general practice is something well documented in literature, but how can individual practices show that their care is making a difference? Numerous PHN activities to support practices, beginning with data quality and completeness, are a foundation. This investment allows us to identify opportunities for improvement to administrative processes and cleanse data to ensure practices are working with data that can be relied upon. NQPHN has developed a comprehensive practice data report based on Australian Clinical Best Practice measures relating to chronic disease. This data consists of measures such as blood pressure, HbA1c, and smoking status, and will focus quality improvement efforts even further. 10

11 Comprehensive primary care: What Patient Centred Medical Home models mean for Australian primary health care Further reading Better Outcomes for People with Chronic and Complex Health Conditions Primary-Health-Care-Advisory-Group_Final-Report.pdf Royal Australian College of General Practitioners (RACGP) Standards for Patient-Centred Medical Homes AMA Position Statement on the Medical Home RACGP Vision for general practice and a sustainable healthcare system: A summary Australian Primary Health Care Nurses Association (APNA) Health Care Homes Position Statement APNAPositionStatementHealthCareHomesJan2017.pdf Australian Association of Practice Managers (AAPM) Position Statement Position_Paper_2017.pdf?ver= The 10 Building Blocks of High-Performing Primary Care Health Care Homes Information Booklet Australian Department of Health Health%20Care%20Homes%20info%20book.pdf Health Care Homes FAQ Booklet September 2017 Australian Department of Health Health-Care-Homes-FAQs-September-2017.pdf Northern Queensland Primary Health Network (NQPHN) Patient Centred Medical Home website 11

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