Right patient at right time. Providing integrated care means that patients get to the right services at the right time.
Clarity of roles and responsibilities. Having clarity of roles ensures that each staff member understands the importance of his/her contributions to patient care and transformation efforts.
Collaborative care. The WQ HCH, including care coordination roles, help facilitate better collaborative care including patient input and connectivity with the wider HCH neighbourhood.
Right information at the right time. The WQ HCH neighbourhood share responsibility for ensuring that the information clinicians need is provided so that they are able to deliver their particular services.
Safe transition of care. All members of the WQ HCH team and broader neighbourhood are responsible for patient care and have a clear understanding of each clinician’s role to ensure safe care transitions.
Care coordination. Care coordination not only helps smooth out logistics and timeliness of services but helps those services work together more effectively.
Emphasis on patient-reported experience and outcomes. Patient reported experience measures adds to quality, and ultimately to value of the service.
Emphasis on self-care. Patients better trained and supported for self-care.
Benefits for patients
The WQ HCH provide proactive patient-centred, coordinated and flexible care with a team of professionals working together to make sure the patient receives care based on their needs. WQ HCH gives patients a better experience through:
Patient Centred Care – each patient has a care plan which is tailored to their individual needs and preferences
Improved Care Coordination – better linkages with hospitals, allied health and other community care providers means a more seamless experienced for the patient
Improved Personalised Care – a patient-nominated clinician (usually their GP or nurse) leads to the care team to conduct a health assessment or develop a formalised, tailored care plan, which is shared with all team members, including the patient and their family / carer
Improved Access to Services – patients can access a member of their care team during the day for support, remotely by phone or email. They do not always need to make an appointment with their GP to get information about their condition
Long-term approach to Disease Management– WQ HCH provides support, prevention and health promotion to improve health outcomes, rather than a reactive approach which focuses solely on treating unwell patients
Challenges
Even with additional resources available, practices still face several potential challenges including:
Engaged leadership - embedding whole of practice change
Ongoing workforce recruitment issues
The disruption of change may add to stress and uncertainty
Not all steps of change will work out well at first; some will seem to have a negative impact until corrected
The need for adequate and predictable payment together with appropriate risk adjustment, especially when caring for high-cost, high-need patients
Interoperable of electronic health records, which are integrated with the primary care workflow, population health management tools, and other technology (such as telehealth for many rural and underserved practices, or mobile applications to connect with patients)
Timely access to real-time, integrated data at the point of care
Stress of trying to make changes in a system where the power to influence feels limited
Small sustainable changes, as encouraged within the WQ HCH program, and as reported by EAPs, can overcome these challenges and lead to more comprehensive and sustainable change overtime.
