Implementation of the Health Care Homes model in Australian primary care

• Published in: International journal of integrated care 2019-08, Vol.19 (4), p.376
• Main Author: Janamian, Tina
• Format: Article
• Language: English
• Subjects: health care homes; implementation; practices; transformation
• ISSN: 1568-4156; 1568-4156
• DOI: 10.5334/ijic.s3376

Introduction: Worldwide health systems face the challenge of providing innovative models for delivering care that ensures high quality, accessibility, continuity and coordination of care. One in four Australians have at least two chronic health conditions and they require services from different health professionals. Often there is a lack of coordination and communication between care providers across different parts of the health system which can be frustrating for patients, their families and carers. It can also put patient safety at risk and cost the health system more. Aim and theory of change: In Australia, the Health Care Homes model was introduced in 2016 to provide: – Better coordinated, more comprehensive and personalised care – Increased continuity of care - Empowered, engaged, satisfied and more health literate patients and carers – Improved access to services – Enhanced sharing of up to date health summary information - Increased productivity of health care service providers Targeted population and stakeholders: The Health Comes model is implemented in 170 general practices and Aboriginal Community Controlled Health Services (‘practices’) across ten chosen Primary Health Network regions in Australia. Timeline: In late 2016, the Department of Health released expression of interest for practices to self-nominate to be involved in the stage 1 implementation. In mid-2017, practices were selected using an eligibility and assessment criteria. The first tranche of practices commenced in October 2017 and stage 1 implementation ends December 2019. Highlights: Participating practices are provided training to support their implementation efforts. Practices use a risk stratification tool to determine patient’s eligibility for enrolment and stratify patients based on their disease complexity and other factors. Identified patients are invited to enrol with a nominated clinician within their practice who will coordinate all their chronic disease management, face-to-face or virtual, within and outside the practice. Rather than the usual Medicare chronic care and planning items currently available for doctors and nurses, practices will receive a single bundled payment per patient per annum, based on assessment of the patient’s complexity using a risk stratification tool. Health Care Homes are free to work with the patient to tailor the care to the patient’s circumstances, clinical need and preference. Opportunities for more innovative use of e-health, both in-h