As those working in general practice know only too well, patients with complex health needs typically suffer from multiple chronic health conditions, functional limitations and unmet social needs.
With such complexity, a patient’s care can often be fragmented leading to concerns about the quality and safety of patient care, and increasing the risk of potentially-preventable hospitalisations.
SWSPHN’s new My Care Partners program aims to improve care co-ordination between the patients’ medical home, primary and community services and acute care, and ultimately improve outcomes for patients with complex and chronic conditions.
What is My Care Partners?
The My Care Partners program adopts a ‘medical neighbourhood’ model of care and has been co-designed by SWSPHN, the South Western Sydney Local Health District (SWSLHD), primary healthcare providers and community members. It involves a team-based approach to fulfil the individual’s required care needs. Team members include the patient and GP, as well as practice administration staff, practice nurses, specialists and allied health providers such as physiotherapists, podiatrists, dietitians, diabetes educators and psychologists. As an active member of the ‘medical neighbourhood’, practices will work collaboratively with other participating practices to improve the outcomes of a shared cohort of patients. As a result of shared care, the ‘medical neighbourhood’ can achieve ‘shared outcomes’ as well as ‘shared cost savings’ which are distributed among participating practices in the ‘neighbourhood’.
How does it work?
The program will provide participating practices with ongoing support to transform into a ‘patient centred medical home’. General practitioners will enrol patients with complex and chronic conditions who have been identified as at risk of frequent hospitalisations. Participating practices must make a number of commitments including:
- Reviewing reports and working with enrolled patients and their care team to identify needs that can assist in reducing a patient’s risk of potentially preventable hospitalisations.
- Providing protected time to allow for staff training and innovation.
- Installing and enabling digital health applications to improve communication between providers and to track each patient’s journey.
- Working with a SWSLHD Care Enabler and patient care teams to continue to provide team-based care to identify patients’ needs.
What is a SWSLHD Care Enabler?
The Care Enabler is a team member from the SWSLHD who will work with practices and My Care Partners patients to facilitate their care. The Care Enabler will form part of the patient’s care team to:
- Assist patients in navigating the healthcare system.
- Identify additional support for the patient.
- Facilitate communication and appointments with the care team.
- Assist in improving health literacy.
What are the benefits to the practice?
Some of the benefits include:
- Staff trained in digital health readiness and enrolment readiness by the PHN team and Care Enabler team.
- Opportunities for staff to suggest and work on quality improvement initiatives within the practice.
- Learning opportunities for staff, including attending workshops and joining networking sessions.
- Opportunities for staff to network with other My Care Partners practices and external providers in the ‘neighbourhood’ to improve communication and enhance relationships.
- Team-based and patient-centred care.
- Access to payments to set up as a My Care Partners practice, as well as ongoing patient enrolment and activity payments.
- Access to ‘shared cost savings’ distributed across the ‘medical neighbourhood’ for practices who achieve patient outcomes.
What are the benefits to patients?
Some of the benefits include:
- Improved outcomes for patients with complex and chronic conditions including reducing the risk of preventable hospitalisations
- Improved patient experience by encouraging continuity of care and team-based care to reduce the risk of omission or duplication of services
When will the program begin?
SWSPHN has developed a general practice capacity building framework to support My Care Partners practices when implementation begins.
Recruitment has begun in the Campbelltown/Camden Hospital catchment – that is in Campbelltown, Camden and Wollondilly LGAs – before being rolled out across LGAs in the rest of the region. An Expression of Interest has been distributed to practices within the eligible LGAs. A maximum of 25 practices will be recruited for the first 12-month period. Patient enrolment will begin in 2021.
My Care Partners: Information for general practice and other health professionals