IT was a career-changing moment when Dr Harry Pope realised his heart lay as independent GP, and not his then role as an executive, managing health care professionals for Australian corporate, Primary Health Care. He returned to general practice and developed an interest in the concept of Integrated Care and, last year, he was offered a place on the IFIC Fellowship programme, which is aimed at supporting mid to senior level care professionals, managers and policy-makers gain in-depth knowledge and understanding of implementing integrated care effectively.
Here he talks about his fellowship journey, key learnings and how he will use Integrated Care principles to support, develop and implement programmes that have local relevance.
My Fellowship Journey by Dr Harry Pope
Lessons learned and my progress in developing a Patient Centred Diabetic Medical Home in an Australian Corporate General Practice
My motivation for this Fellowship journey has been that for much of my career I have been a strong advocate for my patients as well as for the provision of quality health through primary care physician (PCP) upskilling. Medical specialisation and tertiary care institutions have progressed the deskilling of PCPs. I believe that the future of primary care is where PCPs will transition towards higher skill patient management roles within team care for complex chronic conditions. GPs working at their professional highest level.
I had been in an executive position within the Australian corporate, Primary Health Care. In 2016 I returned to the role of an independent general practitioner (GP) treating patients at the Fairfield Chase Medical and Dental Centre. The reason for the change was that I realised that I had appreciated the role of working as a clinician more than the position of managing the health care professionals within the organisation.
Primary Health Care Limited (Primary), is an Australian corporate organisation with 71 medical centres.
Primary provides healthcare services to 2 million patients per annum. All Primary centres include a range of collocated services that support a Patient-Centred Medical Home (PCMH), such as GPs, Specialists, Allied Health, Pathology Collection, Diagnostic Imaging and Pharmacies.
The Australian health care system is no longer viewed as able to support a universal open-ended health care system financially. The patient population is ageing and has increasing co-morbidities, as has occurred globally. The demand for health services is escalating. The Australian Government is looking for innovation in healthcare and is financially supporting the testing of differing models of care with the view that quality and outcomes are to be the focus of the future health care system.
Historically due to high patient volumes within the Primary extended hours medical centres, the demands placed on the health care practitioners (HCPs) has resulted in episodic care being the predominant model of care.
A program to implement protocols for the conversion of the episodic care focused centres to an integrated care model that often is a collocated model was to be trialled. The conversion was to be based on Bodenheimer’s 10 Building blocks of high-performing medical centres.
The Fairfield Chase Medical and Dental Centre was the trial site, and I am the lead clinician in the Integrated Care Team for this project. An abstract on that project was been accepted for the 1st Asia Pacific Conference in Brisbane.
My interest in quality medicine where the patient and their input is the focus of their medical management. That teams of health care professionals contribute to the patients care through their specific skillsets, as well as the upskilling of GPs, as over time their contribution to the health care system has been devalued as reflected in – “just a GP” statements. From this was born the desire to motivate change within the Fairfield medical centre as well as the corporate organisation. The lack of documentation of patient biometric, demographic and test result data was often times the norm. Shared and handover care had no standardisation with the result that patient follow-up was deficient.
I considered that as professional behavioural change appeared to be resistant to executive level recommendations, rather that continue as a remote leader of change, I had to step into a role of being an example of change management at the clinical patient contact level.
So, in mid-2016 I was supported by both the South Western Sydney Primary Health Network and Primary by a nomination for the IFIC Inaugural Fellowship. I believed the Fellowship would support my personal development within the field of Integrated Cared as well as guide me in my implementing a model of care at the Fairfield site.1
The Fellowship program is a self-directed learning program that provides mentorship by internationally recognised Integrated Care experts. There is also the opportunity to develop networks of experts and contacts within the local and international Integrated Care community. The IFIC Fellowship program has been developed to afford the opportunity of visiting innovative and leading healthcare providers nationally and internationally. I attended the 4th World Congress on Integrated Care in New Zealand, and the Integrated Care Academy program at that meeting was an excellent orientation into the theory of integrated care.
During this past year, as part of the Fellowship, I had been provided with the opportunity to review some Integrated Care models that have been trialled internationally.
The knowledge gained from those models has assisted me in reviewing and evaluating my project.
IFIC colleagues have shared their expertise in their areas of research in integrated care by mentorship. This sharing has at times been one on one sessions, but often as part of group learning. Robin Miller had actively encouraged having the one on one meetings with our exchanging ideas and concepts about the differences in our healthcare systems.
Using these events as a grounding for my project, the methodology of the research topic “The Practicalities of developing a Patient-Centered Medical Home (PCMH) for Diabetes Care in an Australian Corporate Medical Centre Setting” was developed. Webinars and leadership programmes were progressed through the Primary Health Institute, a registered educational organisation under the Primary corporation umbrella. An executive Integrated care team was constituted to oversee the project developing a workflow, data analysis and reporting system. An outline was presented at the Dublin World Congress in May 2017. 2
As part of the Fellowship program, I have been called upon to participate in IFIC events, one being the IFIC Scotland webinar series.
During the Webinar, Integrated Care Matters – Series – I presented on Locality Interdisciplinary Teams, from an Australian corporate perspective. Comments from the participants highlighted the different emphasis in Primary Care between the countries, where there is a greater support of social care in Scotland, but with a dependency on volunteers providing significant components of healthcare.
With my participation in the IFIC World Congress Scientific Committee, abstract submission assessments for the 1st Asia Pacific Conference, I have gained experience in assessing abstract submissions. Skills developed here helped write my subsequent submissions.
Recently I had also participated in the formation of the IFIC Australia Inaugural Council Committee. The Australian IFIC organisation is likely to be a strong stimulus for knowledge sharing and implementation of integrated care models in a time when Primary care is transforming in Australia.
As an IFIC Fellow, I have presented at the 2017 annual GPCE plenary session on integrated care in Sydney. The audience comments reinforced my impression that Australian GPs feel pressured and even have a sense of persecution due to the past Medicare auditing bureaucracy culture.
Another opportunity to learn from international experiences, presented itself in the form of the Three Country Study Tour, which in 2017 took us to Scotland, England and Wales. During the Three country tour, a common theme in the countries visited, was that a perfect financial storm, the GFC, had set a climate of Austerity, and this had coincided with a fall in the number of GPs in the UK. The NHS required a new method of providing services that continued to support quality services as well as being cost-efficient.
The first leg of the tour commenced in Edinburgh. The model presented was a top-down version with a strong emphasis on social care with enabling legislation and being reliant on the 3rd sector support via grants, donations, voluntary income, but moving towards public funding. The vision is to have an Alliance of Health and Social care services.
My impression was that there was a strong spirit of collaboration between health service providers that we visited. Community support was more actively involved and organized than in the Australian system. 3rd sector support is very siloed from primary care in Australia.
At St Andrew’s, the group met with Scottish Government officials and a robust discussion developed about the changes that the new GP contract needed to encompass to be more able to cover the expanding nature of Primary care rather than be restrictive. Also, the disadvantages of the past QoF (Quality and Outcomes) system and its failings to support comprehensive holistic care were outlined noting that the result had been skewed by tick box care having been the result rather than comprehensive care outcomes.
Such developments in the Scottish system are being promoted via remodelling the system through appointing GP clusters with data reporting and allowing social prescribing. In Australia, the reality is that these elements are only in the planning phase. Australian Allied Health Practitioners in Chronic care management are severely limited in the quality and quantity of service that they can provide. Not a truly holistic comprehensive care system.
The second leg of the three country tour commenced in Shrewsbury where the Bevan commission was outlined as the social model of health essential for prudent health, integration and to redefine the relationship between health professionals and citizens. The term Prudent Care was discussed where healthcare is conceived, managed and delivered cautiously characterised by careful budgeting achieving tangible benefits and quality outcomes.
This concept allows the HCP to trial models.
An Urgent Care Practitioner (UCPs currently are paramedics) would assist in care such as attending nursing homes, to remove some of the burden on GPs.
Another model demonstrated was – a Key Team Model which consisted of the GP, a nurse practitioner, Pharmacist, Occupational therapist and coordinator. This contrasted with the Australian system where competition exists between retail pharmacies “performing GP work”, and where tele and video consults are excluded from the National Medicare system bar very specific limited reasons, as in remote areas. These functions were fundamental to the Key Team Model.
Many UK models are programs for ‘deloading or unburdening’ the GP. Australia is graduating an ever-increasing number of Medical practitioners and still commissioning more Medical Schools and GP numbers are not significantly insufficient in comparison, bar the remote and regional areas.
The third leg of the study leg was in Manchester. A particularly attractive model to me was presented at Salford – ‘Salford Together’. Where a community Asset program, involving social care and primary care have impacted the community health and well-being by developing new roles, for adult care solutions. The ‘human library’ community knowledge officers concept and the key worker model, where an officer moves about in the community and gains information about the community and develops a social care register, e.g. to organize that betting shops can provide male health programs on prostate Ca, and testicular cancer is particularly relevant to projects I am currently involved in.
The fellowship program has supported my development and understanding of the varying models that exist internationally. My key learnings have been that the Australian healthcare system needs to progress towards healthcare having a focus on the “quadruple aim, enhancing patient experience, improving population health, reducing costs …. and improving the work life of health care providers” 3, The new generation of HCPs value work-life balance and the triple aim can engender professional burnout without the latest component, practitioner satisfaction. In a fee for service system where the incentives have in the past encouraged quantity as opposed to holistic care, read quality, Australia is searching for innovative ways of addressing the shortfalls in the current healthcare system.
The Osana model of care, 4 proposed by Dr Kevin Cheng, has a patient membership system that focuses on integrated care principles by “we activate patients using a membership-based, customer experience model. Patients will each get a health coach, free education classes and community activities, and a clinical coordinator to monitor their health and help them achieve their health goals.” This proposal will be funded by Australian investors looking for long-term health outcomes with a financial reward for delivering those outcomes. This program will be dependent on a return from savings that the “quality GP” generates through better care, less cost. I am not aware of any incentives that the Australian and State Governments, are considering in principle to support this or related models.
Differing health care systems have common integrated care goals. The difference in the models utilised is often determined by the financial contribution of the participants – governments, professionals, patients, NGOs and community carer groups. Often the model can be transposed from one system to another with modification to accommodate medicolegal requirements or financial constraints.
An example is the waiting room concierge in the Salford area, who was a non-medically trained medical centre support person who redirected patients that were assessed as not requiring a GPs attention but, for example, seeing a pharmacist for a cold would be more time and cost efficient. Primary Health Care is trialling in some centres this concept but the assessor has been determined to require a nursing qualification. This is a concept transfer, with a modification to suit the medico-legal culture.
As for my research project, “The practicalities of developing a Patient Centred Diabetic Medical Home in an Australian Corporate General Practice,” there were significant outcomes in developing the chronic care coordinator role as well as a positive culture change within the centre supporting the integrated care model. The results were confounded by the arrival of seven thousand Syrian refugees into the Fairfield local government area. The Fairfield center has had an Arabic and Assyrian culture base. This resulted in an increase in assessments and care coordination at a level that overshadowed the diabetic medical home model. Using these developments the model is being redeveloped to encompass chronic conditions in general, as well be demonstrated into the other Primary Medical centres.
What of the future?
The future in Australia is in developing programs that expand Integrated care to encompass the social determinants of health. I am, as the Chair of the Fairfield Health Council, a Primary Health Network initiative, promoting the development of the Fairfield Health Alliance, an alliance between Federal and State Governments with the Fairfield City Council to develop and implement programs that have a local relevance.
Through community representative advice a number of focus areas have been identified as priorities
These are :
- Group one: population domain (disadvantaged CALD groups and newly arrived refugees).
- Group two: workforce domain with the inclusion of prescribing patterns sub-category.
- Group three: mental wellbeing; and mental health.
- Group four: diabetes and circulatory diseases; and liver cancer and hepatic disorders.
- Group five: immunisation; and cancer screening.
- Group six: wellbeing smoking; and wellbeing gambling.
The Alliance will work towards progressing these domains into local culturally appropriate programs.
Recently I attended the Inaugural IFIC Australia Council meeting with representation on the council by IFIC, IFIC Scotland, Australian members, PHNs, Local Area Health, Universities, and the Australian Centre for Innovation. I hope to be able to be active within the Council to progress the IFIC mantra “ that brings people together to advance the science, knowledge and adoption of integrated care policy and practice.”
Inaugural IFIC Fellow
1.The practicalities of implementing a Patient Centred Diabetic Medical Home – IFIC website blogg 29th Oct 2016
2. WICC 2017 Dublin abstract presentation and 1st Asia Pacific abstract presentation
3. Ann Fam Med. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713. From triple to quadruple aim: care of the patient requires care of the provider. Bodenheimer T1, Sinsky C2.
4. firstname.lastname@example.org – www.osana.care