dr tony lembke - alstonville clinic - expanding the role of phi to enter primary care

Primary Care and PHITony Lembke, Sydney 29th July 2015

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alstonville

• The Person Centred Health System

• The Medical Home

• General Practice Funding

• General Practice working with PHI

• Australian Medical Home Groups

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Professional

Financial

Community Value

What does an effective health system look like?

The Person CentredHealth System

Home Medical Home Community Hospital


All layers are important- Strengthen each layer so that less people ‘filter

out’ to outer layers- Keep specialised / hospital layers free for those

who really need them


Resources in the centre of the system

- Patient preferred- More effective- Less expensive- Whole person (vs disease specific)- Generalist vs Specialist


Integrated Care Teams- Each person and their carers can partner with

the team they need to manage their health- This team is joined up- While the team gets larger and smaller depending

on the person’s needs, the core team is constant- People are not ‘transferred’ from team to team

The 10CCs of Chronic Condition Consultations(the Things We Do for Love)

Comprehensive CoreConcerns and ChangesCare Team and CommunicationsChallengesConditionsConcurrencyConfidenceCalendarChoresCharge


Teams


MEDICARE LOCAL LHD

The Person Centred

Health System

What does quality General Practice look

like?

The Australian Medical HomeAll Medical Homes are General

Practices…..

but not all General Practices are Medical Homes

The Australian Medical Home

Your medical home is the general practice you choose to be

accountable for your ongoing health care.

Accountability

Ongoing Care

The Australian Medical Home‘Ongoing care’ means that patients and their families have a continuing

relationship with a particular GP.

In the medical home model, this partnership is supported by a practice team, and other clinical services in the ‘medical neighbourhood’ wrap around

the patient and their families as required.


New Roles

The Australian Medical Home

Five aspects to care in Medical Home…..

Patient Centred

Comprehensive, Whole of Person Care

Coordinated


RolesPractice nurses as

chronic care managers


RolesPractice nurses as care coordinators


RolesBehaviouralists

DieticiansExercise Physiologists

Educators

Accessible

Quality and Safety

Home Medical Home Community

Primary Health Networks

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AccessQuality

Integration

PRIMARY HEALTH NETWORKS

Home Medical Home Community

GP Funding

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PRIMARY HEALTH NETWORKS

GP Funding• Fee for Service - GPs

• Fee for Service - Team

• Patient Enrolment

• Chronic Disease Funding

• Nominated Patients (non MBS)

• Quality Payments

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GP and PHI

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Bending the Curve

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Extra Care

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Fortnightly videoconference / phone call ONnursHome visitation by the practice nurse quarterly, and

within a week of hospital discharge, and on additional occasions when clinically indicated

reports to the Australian Medical Home Group on key clinical parameters for these patients

monitoring and discharge planning by the patient’s GP and practice nurse for the patient when

hospitalised

an appointment with the patient’s usual GP within three days of hospital discharge, whenever

practical.

Health maintenance/coaching

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Australian Centre for the Medical Home

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Register of Australian Medical Homes

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Australian Medical Home Groups

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dr tony lembke - alstonville clinic - expanding the role of phi to enter primary care

Healthcare