April 2018
No Images? Click here
Enrolment of patients is now underway
Patient 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 patients
Use 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:
- “We'll contact patients when they come in for an appointment.”
- OR: “We’ll make a list and call/SMS/email/send them a letter.” Adapt the template for contacting patients, available under practice resources.
Explain Health Care Homes
When 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 patient
Think 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 form
If 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 patient
Flag the patient in the clinical system and the practice management system. Register the patient in HPOS.
More on enrolment
Module 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:
- Precedence Healthcare with questions about the RST: 1300 236 638.
- The Department of Human Services with questions about HPOS: 1800 222 032.
- The department's Health Care Homes hotline: 1800 290 637
- Resources to support enrolment are also available on the Health Care Homes website.
Clinical champion
Paul Burgess, clinical director for coordinated care, Top End Health Services, NT
Tell us about your background in integrated care?
“I was Australia’s Harkness Fellow in 2014-15, spending a year in the US, looking at the patient centred medical home applied to vulnerable populations.
“I’ve also lived and worked in the NT for 17 years in community controlled and government PHC services. The Aboriginal primary health care model of care is similar to the HCH model. We practice team-based primary health care with multi-disciplinary teams and have sector-wide, data-driven health care improvement through national key performance indicators. In many respects we’re ahead of the pack with the [Health Care Home] reforms.”
Have clinics in remote settings always had to depend on team work?
“Team work is absolutely critical. We’re only as good as the weakest member in our team. Necessity is the mother of innovation. Because of our very challenging circumstances [in the NT], we’ve also always had a tradition of embracing and leveraging innovation.”
What does chronic disease look like in the NT and in remote communities?
“There’s good research for the NT showing very premature onset of chronic conditions. We see chronic diseases impact our population up to two decades earlier [than mainstream settings in Australia].
“With cardio-vascular disease for example, it’s not uncommon to see Aboriginal residents in their 20s and 30s have acute myocardial events. We see Type 2 diabetes in our teenage population.
“Many of our chronic care indices are underpinned by the social determinants of health ― very tough living circumstances, low levels of formal employment, high levels of overcrowding in housing, and food insecurity.
“We’re excited by the opportunity to increase Aboriginal participation in the delivery of care in all aspects of primary health care, whether that be early detection, health promotion or better self-management, care coordination and coaching around chronic conditions.”
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?
“Health Care Homes is an extremely welcome reform for us because this model is less dependent on face-to-face consultations with GPs. We’ll be able to build on what we already have in terms of robust team-level care in remote primary health centres.
“What’s really exciting is the potential for more virtual contacts of care, so rather than someone in a small community having to wait a week or a month for the GP to visit, we can do a lot more by telemedicine. There can be a key role for Aboriginal staff who will run those telemedicine sessions and be the care coordinators or navigators.
“We’re very interested to see what services in the NT do with this opportunity. We have some services that are already using social media, like closed facebook groups, for patients in their service.
“I think this trial will create a space for innovation and adequate reward for innovation.”
Why are you interested in data-driven approaches to healthcare improvement?
“Data saves lives, there’s no doubt about it. The intelligent, meaningful use of data improves care processes and improves access to care. In my clinical practice I’ve seen that change lives.
“Data can be absolutely transformative in terms of team function too. Instead of people having differences of opinion based on their opinion, people are focusing on the data and thinking about their patients, and real outcomes attached to that.”
What’s your approach to motivating patients?
“What matters to the patient is what matters ― whether that’s being around for their grandchild’s 21st, seeing their kids through high school or that long-wished for holiday they want to take in good health. It’s about giving space for patients to articulate what’s important to them, and seeing the role better management of chronic conditions can play in realising that dream.
“Health Care Homes can make that possible. It allows for greater time and space for the important conversations to happen.”
Risk stratification tool override: new factsheet
Enrolling 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:
- patient demographics
- diagnoses
- medical observations
- medications
- lifestyle.
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 trial
The 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 resources
The department has sent participating practices new posters.
Online resources are also available here. Bookmark these pages for easy access:
