International evidence clearly identifies clear foundations integral to Health Care Homes. WQPHN have identified 10 key foundations across three domains (access, prevention and chronic and complex) that support WQ HCH practices. The foundations have been developed in consultation with Mater Research Institute – University of Queensland (MRI-UQ) and set out HCH foundations specific to Western Queensland context over and above the traditional model. The 10 foundations also recognise that WQ HCH practices are on a continuous improvement journey.
In order for WQ HCH practices to be successful there is a need for sustained leadership to activate change and redesign and contribute to quality improvement approaches. This includes building opportunities for clinical and operational leadership including providing training and protected time to conduct activities beyond immediate patient care and administration.
Patients take an active role in a WQ HCH model by taking a leading role in setting and meeting their own health care goals. The patient partnership approach also means the practice has a ‘plan’ for each patient, depending on their health status and risk factors, and care approaches are customised and tailored to their individual needs and preferences. Managing patients in this way is widely recognised as producing better outcomes, and reducing the likelihood of urgent, ad-hoc treatment. This proactive care can lead to better self-management, patient empowerment, and efficient scheduling of patient appointments.
Ensuring better access to cultural awareness programs and tools to build improved competency and safety in primary health care services for Aboriginal and Torres Strait Islander peoples is a fundamental priority. The Nukal Murra Alliance partners will be the primary source for drawing on cultural knowledge and building greater cultural competence and service customisation. Cultural competency is a foundational element in quality, access and service equity and is articulated in individual and organisational capabilities and supported by system design, workforce and clinical service domains.
The WQ HCH Model of Care involves placing an emphasis on planning to ensure the patient receives the right care in the right place at the right time by the right team. Planning enables practices to be proactive in their care, which in turn allows more preventative measures to be implemented. Informed through quality patient data, risk stratification and prioritisation, and supported by shared care plans and interoperability, proactive planned and structured care will better connect and coordinate the extended care team around those people with unstable or more complex care needs.
Engagement in digital transformation is essential to inform and activate patients, to securely share personalised care plans across teams, and to use population health information to underpin quality improvement and resource allocation. Digital technology can be applied to boost telehealth consults for those that do not need face-to-face consultations and also support patient portals for health tracking, appointments and self-management support. Supporting widespread application of appropriate infrastructure and technology and moving towards more interoperable systems will contribute to improved patient outcomes and system performance and efficiency.
Providing support for health professionals to better define roles and distribute tasks within a team-based approach and build proficiency of team members to reflect the skills, abilities, and credentials necessary to achieve individual and practice population outcomes. This allows practices to nurture clinical leadership, ensure staff are working to full scope of practice, expand or create new roles, link with partners or third-party organisations and ultimately improve the work life of health care providers and contribute to more customised and appropriate care.
Through embedding Continuous Quality Improvement (CQI) strategies into daily workflows builds practice capability to deliver responsive patient centred care, that empowers patients to be informed and engaged in the management of their own health care. This Model for Improvements Plan, Do, Study, Act (PDSA) cycle is being used as a structured approach to quality improvement that is considered best practice by RACGP. The PDSA cycle is used to improve processes, implement change and is a simple measurement tool that can be used to monitor the effects of change over time.
Robust and reliable information regarding the population health status and how these needs are changing over time is essential to support effective place-based commissioning and inform service design and delivery options. Primary Care Commissioning in Western Queensland is informed by local, regional and national health indicators, and supported through good data governance to guide data acquisition, aggregation and analysis, and applied health intelligence that will validate and inform evidence-based approaches and quality improvement.
Health infrastructure is a key enabler to supporting more comprehensive and accessible primary health care. Considering how general practice settings can be further developed or reconfigured to optimise efficiency, patient flow, service integration and coordination is a key consideration when activating the WQ HCH Model of Care. Linking in with the wider WQ HCH neighbourhood is important as there may also be opportunities to create value for service users and providers through consolidation of health (and potentially social) care services on a single campus as a ‘health precinct’ or to accommodate the practice and multidisciplinary team (MDT) in a single facility. Creating more multi use clinical space, seamless access to telehealth and virtual clinic’s, and reclaiming passive waiting room floor space for active use have been identified as important infrastructure considerations within a Health Care Home.
For a WQ HCH to be successful it must be underpinned by long term sustainability and a business plan that integrates critical investments including staffing and infrastructure, with patient and population health improvement outcome measures. WQ HCH are supported through the provision of a comprehensive analysis of the practice population health status against contemporary MBS, DVA and private income considerations. This Practice Performance Analysis (PPA) will be annualised to provide measurable targets linked to population health outcomes and productivity, and also guide staffing ratio’s and quality improvement incentive payments. The WQ HCH Progress Action Plan has been customised and linked to 5th Accreditation Standards to integrate the WQ HCH foundations to assist the transformation of the practice in becoming an aspirational WQ HCH.