Navigating the healthcare neighbourhood: Re-framing care around the patient and their primary care ‘home’

Abstract

Introduction : Primary health is the cornerstone of a strong and efficient health system. High performing primary care that is accessible, comprehensive, co-ordinated and continuous, and achieved through contemporary models of care offers the potential to enhance integration, improve patient outcomes and experience, and sustainability. Primary Health Networks are building capacity and capability for general practice to achieve this based on a model known as Patient Centred Medical Home (PCMH). The Australian Government is commencing the roll out of ‘Health Care Homes’ using elements of PCMH and alternative payment structures. To optimise the impact of these primary care reforms requires a supportive and collaborative approach from the broader health system. Practice Change : The NSW Agency for Clinical Innovation (ACI) is supporting services to develop localised integration networks – “Healthcare Neighbourhoods”. Neighbourhoods will operate with the general practice or Aboriginal medical service as the hub and include health and social care services. Neighbourhoods support the practice through engagement with care coordination, shared care planning, effective communication, data sharing, and a team-based approach to care. Aim and Theory of Change : The Healthcare Neighbourhood aims to build a shared purpose for integration and care outcomes, clarify roles and responsibilities, and support collaboration with general practice. It refocusses the health system from operating in silos to integrated implementation with primary care as the hub. ACI will deliver a capability program that builds awareness and knowledge, encourages connections and information sharing, provides tools and resources, and supports implementation of healthcare neighbourhoods. It constitutes a significant component of a change and adoption strategy for a more integrated health economy. Targeted Population : Key beneficiaries are people with chronic and/or complex conditions. The intervention will take place at the meso and micro system. Timeline : Trial sites will commence in October 2017 across three Local Health Districts and Primary Health Networks and will run until June 2018. Highlights : A ‘Navigating the Healthcare Neighbourhood’ website has been launched, bringing together information about PCMH including; definitions, animations and videos, articles, case studies, patient stories, and other resources. Five local events with international experts in PCMH and integrated care have been held. These have been attended by over 200 health professionals from across NSW. Forthcoming : Podcasts with international patient-centred medical home experts Dr Kirsten Meisinger and Dr Nwando Olayiwola will be released shortly. Sustainability : This work is aligned with macro level policy change at Federal and State Government level. The project seeks to establish shared vision and understanding across the health system and explore local opportunities for change and collaboration. Transferability : Our work provides a high-level structure, resources and tools to build healthcare neighbourhoods, which can be tailored to meet local needs and resources.