APNA's definition of primary health care nursing covers health, scope of practice, primary health care, roles and settings. We also explore general practice nursing and Phillips et al. six roles of the general practice nurse.
What will Health Care Homes mean for nurses?
APNA's position statement on the Health Care Homes model demonstrates strong support for an initiative that aims to better assist and support people with chronic and complex health needs.
It will be a setting where patients can receive 'enhanced access to holistic coordinated care, and wraparound support for health needs', and will provide a team-based care approach where patients and carers are active members of the Health Care Home care team. APNA believes the nursing workforce will play an essential role in the success of the Health Care Homes model. Watch the Health Care Homes panel webinar from APNA's 2017 State of the Art Conference.
Continuity of care - Q&A with Anne O’Connor, practice manager and practice nurse from Windmill Practice, Tamworth
Windmill Practice started Health Care Homes in October 2017. Why did your practice sign up?
'We’re a new practice. We’re been open for four years and our motto is continuity of care. Continuity of care and planned care for patients with chronic disease makes sense, so the framework of Health Care Homes fits in nicely with that.'
How many patients have you enrolled?
'We have registered 20 patients under two of our GPs, Dr Louise Badenhorst and Dr Heather Carr.'
'We got the systems in place and the risk stratification tool up and running prior to commencing the registration process. The tool is now working well and is very simple to use.'
Will you have a gradual on-boarding of patients from now?
'Yes. We will do it on an ad-hoc basis, at least until the end of the year. As patients come in, we will have a conversation with them and may suggest that they are suitable to be enrolled in the program.'
'We also have our diabetes register up-to-date now, so we will look at targeting some individuals as well. We plan to adopt a more targeted approach in the new year.'
What are your fees for Health Care Home patients?
'We’re a private billing practice and some of our Health Care Home patients will be charged a private gap fee. However we have set our fees so that neither patients nor doctors will be financially disadvantaged.'
How are you keeping in touch with your Health Care Homes patients?
'The practice has brought a medical assistant on board and we’ve come up with a spreadsheet to collate and monitor co-ordination of care for our Health Care Homes patients.'
'Our medical assistant is responsible for entering the data when a patient is enrolled, finding out when their next planned care is, and if they didn’t have a recent care plan, organising to get it done.'
'Our clinical team works very collaboratively and co-operatively. Our practice nurses will have a coordinating role for the health care home patients. In consultation with the treating GP, they will organise the planning and coordination of care.'
Now that you’ve got your systems up and running and some of your patients enrolled, have you changed the way you do some things?
'We were doing a lot of planned and co-ordinated care already. However, participating in Health Care Homes has nudged us into making our systems more robust, and our planning more methodical, which is a good thing. The program is also allowing us to think about more creative ways of doing things to improve health outcomes for our patients.'
'Some of our patients have mentioned that they find exercising on their own difficult and that costs associated with exercise can be prohibitive. We are planning to start a walking group to support our patients to become more active and the medical assistant is going to be in charge of taking the group, twice a week.'
Left: Dr Louise Badenhorst (left) and Anne O’Connor. Photo courtesy of Windmill Practice.
'To not be bound by fee-for-service and face-to-face contact for service provision is very different. It will take everyone a little while to get their head around that. Change can be a bit daunting, but also very exciting.'
“We are still in the early days. However we are pleased with the progress we have made so far and looking forward to developing new strategies and adjuncts to care. If Health Care Homes gets rolled out further, I believe that we really need to do much more work on prevention. The importance of prevention for chronic disease and the promotion of health and well-being is not being heard well enough. Our future direction needs to be more about health and less about illness.'
Watch: The role of nurses in transformation
Are you a nurse in general practice and involved in the Health Care Homes trials?
This webinar recently presented by AGPAL (with the support of APNA) discusses the nurse role in the transformation process into a Health Care Home, including understanding:
- The role of the nurse as a change champion in implementing the key concepts of the Health Care Home model
- The shift required from the traditional practice nurse role in implementing a new model of care for enrolled patients
- The importance of data in identifying and managing the care needs of an enrolled practice population
Watch: Health Care Homes Panel
APNA curated a panel discussion among primary health care leaders on Friday 5 May at the State of the Art National Conference.
The panel was hosted by Dr Norman Swan and featured:
- Karen Booth | APNA President
- Tracey Johnson | CEO Inala Primary Care
- Janet Quigley | First Assistant Secretary, Health Systems Policy, Department of Health
- Dr Bastian Seidel | RACGP President
- Leanne Wells | CEO Consumers Health Forum of Australia
Here's what they had to say:
The nursing workforce will play an essential role in Health Care Homes. Nurses are highly trained, trusted professionals able to make a significant contribution within Health Care Homes by pursuing truly team based, interdisciplinary care which puts patients at its heart. APNA supports the concept, and the role of patients and carers as active members of the care team.
Karen Booth | President APNA
Patient Centred Medical Homes are well established in many other countries. They enable better utilisation of nurses and a range of other care providers for people whose health profiles warrant additional support. Effectively implemented healthcare homes should reduce stress in clinical teams, improve patient outcomes and deliver better value to taxpayers.
Tracey Johnson | CEO Inala Primary Care
Health Care Homes is a key government initiative to reform the primary health care system. The model aims to deliver more effective care for people with chronic and complex conditions and reduce demand on the acute sector, by encouraging practice level innovation and flexibility in how services are delivered. The staged implementation enables all elements of the model to be tested and validated and participating practices will have a vital role in shaping the potential future rollout of this important reform.
Janet Quigley | First Assistant Secretary, Health Systems Policy | Department of Health
Health Care Homes have the potential to transform primary health care particularly for those with complex and chronic illness. The principle aims of Health Care Homes to encourage more team-based, coordinated and patient-focused care offer the potential of more satisfied health practitioners and patients.
Leanne Wells | CEO Consumers Health Forum of Australia
Q&A with David Menzies, Health Care Homes’ team leader, South Eastern Melbourne Primary Health Network (SEMPHN)
David Menzies is a Health Care Homes' team leader at South Eastern Melbourne Primary Health Network, and recently provided some insights into how his PHN is working with practices to support their transition into a Health Care Home via an interview. Here are his responses.
What’s your background?
In a previous life I was a physical educator (exercise physiologist) in a private rehabilitation hospital. After this role I completed a short stint in occupational rehabilitation and then moved into primary health at a Division of General Practice working on the Sharing Health Care Initiative. At General Practice Victoria, I worked on chronic disease management and Close the Gap, and then on the COAG Healthy Communities Initiative with Fitness Australia.
When I saw this role, I thought it would be a great opportunity to be involved in a major initiative in Australia’s primary health care.
What are your team doing at the moment?
My team came on board in January and were able to build on some great preparatory work undertaken by Rashmi Venkatraman, one of SEMPHNs Provider Support Officers. We then had a good eight months to build up a rapport with practices. That’s been fundamental to our success.
We are on the phone to practices daily and have a weekly schedule of practice visits.
My two colleagues, Mary Reynolds and Leonie Tarrant have incredible on-the-ground experience as a practice nurse and practice manager of more than 20 years.
Our approach to practices has been to take things step-by-step. We are constantly advising practices that this sort of change takes time and that they are not expected to enrol 20 patients on the first day.
It is imperative to get all their systems and processes right. Get the risk stratification tool working, make sure they can register their patients on HPOS and then think about next steps and the model of care from that point.
We’re also advising practices about the approach to the training modules. Some were feeling a bit overwhelmed and not knowing where to start.
Where are your practices at now?
Some practices are just at the point where they are enrolling patients. Others are a little more advanced.
One practice has started to think about what comes next with the patients. For example, how patients identify themselves when they come into the practice, so that the practice team knows which workflows to put in place.
They are also looking at regular phone calls to those patients and monitoring them, so that if there is a change or deterioration, they are on to it immediately.
How many SEMPHN practices are taking part in Health Care Homes?
Eight practices started on 1 October and at least another 16 will start on 1 December. There’s a strong appetite in our catchment for Health Care Homes. Practices are saying, We are doing this well already. Why wouldn’t we try and formalise it?
Practice teams are interested in the potential to innovate with more extensive use of tele-health, phone calls, health coaching and other patient focused models of care.
Below: SEMPHN staff at the Health Care Homes training in August 2017. From left Leonie Tarrant, Rashmi Venkatraman, David Menzies and Mary Reynolds.
Shift focus away from fee-for-service and focus on preventative care using the team, say integrated care champions
As Australia embarks on the stage one trial of Health Care Homes, integrated care champions Dr Kirsten Meisinger and Dr Walid Jammal delivered a seminar to Department of Health staff, during a visit in late April.
“Patient–centred care has been part of GP training all along, and the really wonderful, really rich practice that many of the GPs do in Australia,” said Dr Meisinger.
Dr Meisinger is the incoming Medical Staff President for the Cambridge Health Alliance, a practice based outside Boston, Massachuttsetts, USA. She has done extensive international consulting on the patient-centred medical home model and is a consultant on the Health Care Homes training resources.
But as people are living longer, “many of the diseases that we’re trying to care for require a different model of care” to the episodic care model, she said.
Patient-centred and team-based care “is challenging because all physicians have been trained to work really [independently]”.
“We feel that responsibility very much on our shoulders. One of the beauties of team-based care is that [responsibility] is actually a bit of a burden and you do see alarming rates of physician burn out,” she said.
“One of the wonderful parts that team-based care has brought to our practice is that sense that you’re not alone,” she said.
The burden of walking with the patient through their journey “is shared among the team, and that is a very empowering structure for the team, for the patient and for the GP”.
When the focus moves from the GP to the patient “the GP likes it more, gets home earlier, feels that they have done a better job and staff feel more important and more essential to the care of patients,” she said.
Dr Jammal told staff at the seminar that Health Care Homes is an opportunity "to shift the actual focus a little bit away from fee-for-service and really focus on preventative care... using the team".
Dr Jammal is a Sydney-based GP and clinical lecturer at the University of Sydney and Western Sydney University.
“[The GP] cannot do everything. Yet I am trained to actually do everything. I’m trained to say... nothing is done without me being involved,” Dr Jammal said.
With integrated and team-based care, the GP is freed up to change tack and do the “really high-thinking clinical work”.
Dr Jammal is also a consultant on the Health Care Homes training resources.
Health Care Homes to start in two phases, 200 selected practices released
Health Care Homes services will now have a deferred and phased start this year, under measures released in the 2017 Budget. Twenty practices will begin Health Care Home services on 1 October 2017, the other 180 practices will begin on 1 December 2017.
Risk stratification tool to target the right patients
To help Health Care Homes target services for people with chronic and complex health conditions, they will all use the same risk stratification tool to identify eligible patients and place them in the appropriate tier.
Precedence Healthcare has won the tender to develop and implement the risk stratification tool and will work with CSIRO on both aspects of this project.
The risk stratification process will help providers identify patients who are eligible to enrol and to assess those patients’ risk factors, including the likelihood of unplanned hospitalisation.
Health care providers will assess the clinical and non-clinical factors that affect their patients’ health.
Patients will be asked for their consent to use their health and personal information for these purposes.
Further information on patient identification is available on the patient eligibility factsheet.
Apply to become a Health Care Home
General practices and Aboriginal Community Controlled Health Services (ACCHS) in selected regions around Australia can now apply for stage one of Health Care Homes.
Health Care Homes will improve the provision of care for people with chronic and complex conditions. Participating general practices and ACCHS will play a vital role in shaping this important reform.
Ten Primary Health Network (PHN) regions have been selected for stage one. They are Perth North; Northern Territory; Adelaide; Country South Australia; Brisbane North; Western Sydney; Nepean Blue Mountains; Hunter, New England and Central Coast; South Eastern Melbourne; and Tasmania.
To apply, a general practice or ACCHS must:
- Be located in one of these ten PHN regions
- Meet the eligibility and assessment criteria set out in the application form and guidelines.
A webinar was also held by the AAPM on 5 December 2016 which can be viewed here.
Applications close Thursday 22 December 2016.