The practicalities of implementing a Patient Centred Diabetic Medical Home

In his first blog as part of his Fellowship with the Foundation, Dr Harry Pope discusses how the Australian government is looking for more “cost neutral” ways of delivering medical services within a primary care setting.

With increasing healthcare costs and an ageing population the Australian government is looking for more “cost neutral” ways of delivering medical services within a primary care setting.

To encourage general practice to move from episodic care to more patient-centred care, the Australian government has frozen the Medicare rebate, issued enhanced care item numbers for the billing of GP management plans, team care plans, health assessments and has introduced practice and service incentive payments. From July 2017, the Australian government will also commence two year trials of its Health Care Homes program.

As a current practitioner at Primary Health Care Limited (Primary), a public-listed healthcare company which operates 71 medical centres across Australia and consults 2 million patients, there are major opportunities for integrated care to improve patient management that could result in wide-scale outcomes – potentially affecting almost 10% of the Australian population.

I will be completing a research paper through the International Foundation of Integrated Care (IFIC). My research will be based on Bodenheimer’s 10 Building Blocks of High Performing Primary Health Care. The focus will initially be on the 4 foundational pillars of primary care – engaged leadership, data-driven improvement, empanelment and team-based care.

The IFIC fellowship program will provide me with exposure to international integrated care frameworks and additional input from researchers and practitioners who embed integrated care methodologies into their daily practice. I can then tailor the approach to be best suited to the Australian healthcare system.

In my proposed research, I will:
– Document the practicalities of the implementation of Bodenheimer’s 10 building blocks of general practice at Fairfield Medical Centre (owned by Primary) where I practice.
– Use the framework to develop a Diabetic care model within a primary care setting.
– Address whether a determined workflow and team empanelment encourage the utilisation of chronic care management resulting in continuity of care.
– Interrogate the impact of using a standardised software (Medical Director software) to enter patient data which would enhance interconnectivity. The software program also allows easier patient identification by categorisation either by diagnosis, and / or biometrics or pathology.
– Use the learnings to improve future implementations in transforming other medical centres to Patient Centred Medical Homes.

The implementation strategy will be modified to accommodate the Australian healthcare system, which is funded in part by Medicare, for general practice. Enablers and barriers to the establishment of the patient centred medical home for the Fairfield Medical Centre will be addressed initially through the clinical education interventions for the Healthcare practitioners via structured clinical meetings, involving key members of the care team who have already been recruited to the centre. Clinical intervention pathways and work flows will be documented for consistency in the approach to the management of the patient within the medical home.
I certainly hope funding models in the future will make the implementation of Health Care Homes sustainable so as to deliver improved patient outcomes effectively

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Harry Pope
General Practitioner
NSW, Australia