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Imagine your patient has had multiple organ transplants, suffers resulting chronic pain and is in cognitive decline. Your patient is taking a large number of complex medications under numerous specialists. Your patient’s situation is difficult, both medically and psychosocially.
What can you do to help them?
This scenario is likely not difficult for most GPs to imagine, given the role of primary carers in treating patients with chronic and complex health conditions – including diabetes, respiratory and cardiac disease – which lead to frequent presentations at hospital emergency departments.
A new program which adopts the ‘medical neighbourhood’ model of care has been developed specifically for this cohort of patients, to better co-ordinate and enhance their care and ultimately, to reduce unnecessary hospitalisations.
SWSPHN and South Western Sydney Local Health District (SWSLHD) have collaborated to develop My Care Partners, in consultation with community and healthcare providers. The program is unique to our region, and is tailored to suit the particular circumstances of individual practices.
Why was the program developed?
My Care Partners has been developed to achieve the Quadruple Aim for healthcare of:
- improved population health
- improved patient experience
- improved provider experience
- reduced healthcare expenditure
It recognises the necessity for GPs, specialists, hospitals and other clinicians to work in partnership to provide complete and coordinated care to patients with chronic and complex health concerns, to:
- reduce potentially preventable hospitalisations
- generate cost savings to the acute sector which are then redirected into primary care
How does the program work?
Participating GPs identify patients who may be eligible to participate in the 12-month program. These patients are referred to SWSPHN’s Care Enablers who assess the patient’s eligibility for the program.
Once enrolled, the patient has regular check-ins with members of the healthcare team which includes SWSLHD’s Care Coordinator, the GP, practice nurse and other members of the care team, such as allied health professionals and specialists.
The care team work together to identify other healthcare providers who may be beneficial to their patient’s care, other services their patient may be able to access, facilitate access to transport, and provide funding to support small home modifications and equipment.
How are patients referred and assessed for the program?
Patients identified as at risk of hospitalisation by GPs or via the SWSLHD Patient Flow Portal are referred to My Care Partners for assessment. The Care Enabler confirms the patient’s eligibility for the program, registers the patient, and alerts the patient’s GP and Care Coordinator to their enrolment in the program. The Care Coordinator undertakes a comprehensive health assessment and determines which of two intervention pathways are suitable for the patient.
The pathways include:
Care Coordination
Coordinates and connects patients with service providers to empower patients to better understand and manage their health, and to seek additional support when required from services including Meals on Wheels, community transport, counselling, podiatry, disability or aged care services.
Care Navigation
Facilitates access to services for the patient, their carers and family for a defined period of time, to improve the timeliness and appropriateness of care, reduce barriers to accessing care, reduce failures to follow up, and/or supports patients to navigate the health system.
What happens once patients are accepted into the program?
Once a patient is accepted into the My Care Partners program they will have a dedicated care team, led by their GP, to provide extra support to work towards better understanding and managing their condition.
The team communicates with each other regularly in the first three months of the program and all work with the patient to understand their goals and to support them in achieving those goals.
GPs arrange case conferences with the patient’s care team – and the patient if they would like to attend – at key points of the program to discuss how best to support patients with their condition and health goals.
How does SWSPHN support My Care Partners practices?
Practices receive support through a 12-week capacity building process which involves:
- nominating practice representatives to participate in training
- establishing processes to incorporate My Care Partners into their workflow
- completing dedicated training on how to refer and enrol patients, and successfully complete program deliverables
As patients are enrolled, practices receive ongoing support from their My Care Partners Project Officer and Care Enablers to embed the program into their workflow and identify opportunities for improvement within their practice.
Communities of practice are also held to bring practices together to share experiences and knowledge, and to problem-solve to ensure the program is continually improving. A recent community of practice discussed case conferencing.
Who is participating in the program?
Sixty-five patients with chronic or complex conditions received care from five practices across Campbelltown, Camden and Wollondilly in Wave 1 of the My Care Partners program. SWSPHN is now recruiting practices for Wave 4 of the program, with the aim of 10 practices per wave.
In two years, it is hoped 60 general practices across South Western Sydney will be part of the program.
How have general practices and patients responded to the program?
Practices and patients have provided positive feedback about their experience of the My Care Partners program.
Patients have described the program as a positive experience, saying they felt cared for and listened to, while general practices have praised the support they receive from the My Care Partners team.
To continually improve My Care Partners, SWSPHN is engaging with expert evaluators to gain insight and feedback on the program.
If you have questions about My Care Partners download the information booklet (28-pages) or email SWSPHN – My Care Partners.