April 2018 No Images? Click here Enrolment of patients is now underwayPatient enrolment for Health Care Homes is now underway. The steps to guide you through enrolment are summarised below. More detailed information is also available in section 4.3 of the Health Care Home handbook. Run RST and contact patientsUse the practice scan in the risk stratification tool (RST) to make a list of potentially eligible patients. Then think about how you will contact these patients:
Explain Health Care HomesWhen you see the patient, give them the brochure, handbook and factsheet. Explain the benefits of enrolling with you as their clinician ― i.e. they get better access to you and to your clinic. Invite them to book in a long consultation. Long consultation with patientThink about how you will structure this consultation; and how you will explain the benefits to your patient in more detail. Have some answers ready for common patient concerns. Print out useful practice resources or customise templates for your practice. Use the questionnaire in the RST to confirm patient eligibility; and determine their risk tier. Patient signs consent formIf the patient agrees to enrol, they can now sign the consent form. Schedule a time to develop a care plan with the patient. Think about who in the practice will do this. Register the patientFlag the patient in the clinical system and the practice management system. Register the patient in HPOS. More on enrolmentModule 3 of the online training focuses on patient enrolment; payment processes; and provides materials to use within your practice. Contact your local PHN practice facilitator to arrange access to this training. Your practice facilitator is also your first point of call for enrolment queries, and can help you develop an enrolment approach and plan. In addition, you can call:
Clinical championPaul Burgess, clinical director for coordinated care, Top End Health Services, NTTell us about your background in integrated care?
Have clinics in remote settings always had to depend on team work?
What does chronic disease look like in the NT and in remote communities?
The NT has almost 15 per cent of participating Health Care Homes. Why has the take up of the stage one trial been so high in the NT?
Why are you interested in data-driven approaches to healthcare improvement?
What’s your approach to motivating patients?
Risk stratification tool override: new factsheetEnrolling a patient in a Health Care Home involves the use of the risk stratification tool (RST). The RST includes a predictive risk model (PRM) and scans a practice’s electronic patient records to determine patients’ eligibility. To determine eligibility, the PRM examines more than 50 variables and interactions, including:
Patients with chronic and complex conditions and a high risk of hospitalisation within the next 12 months are most eligible for enrolment in a Health Care Home. The PRM should identify eligible Health Care Home patients. If the PRM does not identify a patient as potentially eligible, and a clinician believes they qualify, the PRM override can be used. The override was installed to manage any potential issues that arose from the introduction of the tool and should be used by exception. To use the PRM override, a valid clinical justification must be provided. A valid reason is important as it allows the department to understand in what ways the PRM isn’t working as well as it should. This information can then be used to improve the PRM and provide a better experience of the risk stratification process for clinicians. More information is available on the RST fact sheet. Evaluating Health Care Home trialThe department has contracted Health Policy Analysis (HPA) to undertake an evaluation of the Health Care Home trial. HPA has developed a detailed evaluation plan. The evaluation is an important component of the Health Care Homes trial. It will help the Government understand how the Health Care Homes model was implemented in general practices and Aboriginal Community Controlled Health Services, including assessing what has worked well and where there have been barriers. It will also examine the impact the model has had on patient experience of care and whether the changes in delivery of care have led to better health outcomes for patients. The results of the evaluation will be used to shape the program for the future to ensure it is a workable model for practices and services, and that it better meets the needs of patients with chronic and complex conditions. The success of the evaluation hinges on the quality of data that is collected; both to establish an accurate baseline at the beginning of implementation, and to measure change throughout the stage one trial. If you are asked to complete a survey, attend an interview or contribute to a focus group discussion, remember that this is your chance to contribute your views and suggestions to help us shape the model. New practice posters, information and resourcesThe department has sent participating practices new posters. Online resources are also available here. Bookmark these pages for easy access: |