The Australian Health Care Homes: Our Transformation Journey

Dr Tina Janamian

National Manager, Research, Innovation and DevelopmentAustralian General Practice Accreditation Limited (AGPAL)Quality Innovation Performance (QIP) and QIP Consulting

Background

• Worldwide health systems face the challenge of providing innovative models for delivering care within primary care that ensures high quality, accessibility, continuity and coordination of care

• PCMH model shows promise in tackling some of these challenges

• Various definitions and variations of the model but core principles frequently cited in relation to PCMH include:– Wide-ranging team-based care, patient-centred care, care that is coordinated across all elements of

the health care system, enhanced access to care that uses alternative methods of communication, and a system-based approach to quality and safety

• Evidence suggests that adoption of the PCMH model can positively effect care quality in the following areas:– Improved access to care – Improved clinical parameters/outcomes – Better management of chronic and complex disease care – Improved preventive care services – Decreased use of inappropriate medications – Better condition-specific quality of care – Decreased hospital admissions and readmissions – Improved palliative care services

Effect/impact of PCMH on patients

• Improved access to patient-centred care (e.g. access to same physician, reduction in appointment waiting times)

• Improved patient experience of care over time - satisfaction with the team-based aspects of PCMH and the care setting

• Improved chronic disease management

• Increased patient education & involvement in their own care

• Improved communication with patients

PCMH transformation journey begins…….

• In Dec 2012, then Minister for Health Tanya Plibersek announced a focus on the PCMH as a model of interest to combating issues related to an aging population and growing incidences of chronic and complex conditions

• RACGP has been a consistent champion of PCMH model, urging adoption of its elements as part of current reforms and calling for the federal government to fund and implement key elements in its 2013–14 budget submission

• UQ was commissioned to conduct systematic review of literature to better understand existing evidence on PCMH – Safety and quality of care implications of PCMH models in North America, and their relevance to

existing Australian primary care service delivery

– What key elements of the PCMH can be applied to Australian primary care

– Transformation efforts, actual change processes

– Challenges/barriers to implementation and adoption

Systematic review of evidence

Search & inclusion criteria • Searched databases PubMed and Embase using the terms “patient centered medical home”,

“patient centred medical home” (MESH headings) in title/abstract

Publications between 2007-2012 and in English

Studies considered for inclusion - used or mentioned some components of the patient-centred primary care collaborative (PCPCC) Joint Principles of the PCMH

All citations imported into an electronic bibliographic database (EndNote Version X5)

Study selection, screening, synthesis– Screening & inclusion – titles/abstracts of identified studies screened independently by 2 reviewers for

relevance to key questions using screening assessment form to select relevant studies

– Full-text screening: articles included during initial screening underwent full-text screening by content expert reviewer & indicated a decision to include/exclude article for data abstraction

– Data extraction: researcher with clinical and methodological expertise extracted data from eligible articles using data extraction form. Second researcher reviewed completed abstraction forms alongside the original article to check for accuracy and completeness

– Synthesis matrices were used to sort data relating to each key question

Results

Barriers to implementation of PCMH model

• Challenges with transforming primary care system to the PCMH model -complex endeavour that requires substantial time, energy, and resources

• Difficulties associated with change management at different levels of health system & at practice level - lack of readiness for change, scarce resources, and change strategy efforts/interventions need to alter the delivery system beyond individual practices

• Challenges in creating/sustaining an EHR that administers the principles of PCMH

• Issues related to broad acceptance & adoption of the model

• Inadequate knowledge, resources & or support for successful adoption

• Lack of standards & accreditation & inadequate measures of performance

• Challenges with funding and appropriate payment models

Lessons learned for implementation

• Requires fundamental transformation of the health care landscape that promotes/support PCMH model (e.g. coordination, close ties to community resources, payment reform….), long-term commitment, reasonable expectations/timeframes

• Enhancing readiness for change is important - positively impacts implementation process, uptake and sustainability of PCMH

• EHR and “meaningful-use” of EHRs need to support and be linked with features that PCMH model

• New payment structure/incentives vital – transformation payments to support establishment of PCMHs, encourage practice/practitioner buy-in, build/maintain EHR, and then regular payments/incentives to sustain/improve PCMH and patient care delivery

Health Care Home Phase 1

In Dec 2015, Department of Health’s Primary Health Care Advisory Group (PHCAG) provided a report to the Australian Government – Better Outcomes for People with Chronic and Complex Health Conditions, with a key recommendation that Health Care Homes (HCH) be established as a model of care

Benefits for practices and services Benefits for patients

Better experience of care delivery for clinicians through:

Removal of a number of Medicare item restrictions will

reduce pressure on practices by allowing for delegation to

nurses and other team members who can then function at

the top of their scope of practice

More flexibility leads to increased clinical and organisational

efficiencies and removes duplication of work

Bundled payments to align with model of care and reward

value over time rather than volume

Support innovative team-based approaches to deliver care

for patient needs (better communication, collaboration and

comprehensive patient care)

Clinical development and leadership opportunities.

Increased flexibility around how care is provided, such as

support for group health coaching

Reduced red tape for patient access to allied health, mental

health services and home medicine reviews

Better experience of care for patients through:

Patient-centred care based around an individual patient’s

needs and preferences.

Improved coordination of services, including links with

hospitals, allied health and other community care providers.

Improved personalised care through a more formal link with

the patient nominated clinician (usually a GP) leading the

care team developing and delivering their tailored care.

Improved access to services, including remote support such

as phone, email or video conference where clinically

A long-term approach to disease management, support,

prevention and health promotion to improve health

outcomes.

Benefits for the health system

• Improved access arrangements to the right care at the right time will reduce demand on hospitals

• Improved care coordination will improve patient outcomes and reduce escalation of conditions

• Better patient self-management and a shift of focus from episodic treatment to long-term support, management and prevention strategies

• A more responsive system that meets the needs of patients in a proactive way

• Better use of data will build a culture of continuous quality improvement and will assist with needs analysis and resource allocation

• Health system savings through greater efficiencies

PCMH Phase 1 implementation (2 year trial)

• 200 practices, up to 65,000 patients, across 10 PHN regions – Perth North; Northern Territory; Adelaide; Country South Australia; Brisbane North; Western Sydney;

Nepean Blue Mountains; Hunter, New England and Central Coast; South Eastern Melbourne; Tasmania

• To apply, a general practice or Aboriginal Community Controlled Health Services (CCHS) must: Be located in one of these 10 PHN regions; Meet the eligibility and assessment criteria (e.g. accreditation against RACGP standards, agree to participate in training, register to My Health Record system etc.). EOI have commenced.

• Patient identification tool will be used to select suitable patients (takes into account patient’s complexity for determining eligibility for enrolment)

A long learning journey ahead….

• Substantial transformation required for health care system, primary care practices and services, whole care team, patients/families

• Enablers

– National approach and evaluation – Phase 1 trial provides opportunity to learn to inform future roll-out

– A new payment approach – 3 levels of bundled payment linked to complexity and need of patient

– Shared care plan – development/use of tailored and dynamic shared care plan by team and patient

– My Health Records - participating services required to register and use the My Health Record system

– PHNs and training and ongoing support – play vital role to support implementation at practice level; train-the-trainer approach with 10 PHNs; PHNs will train and support practices; training will consist of intensive face-to-face workshops, webinars and self-paced modules over 12 months (including 3 months prior to commencement)

– Dedicated resource and support - $10,000 to support practice change; tech support; web-based leadership series; virtual hub for knowledge sharing

Any Questions