HOW IT WORKS
The Health Care Home (HCH) programme is a patient-centred model of care delivered in a general practice setting. Proactive care for patients with high needs is one of the four key domains of the programme, with a focus on patient self-management and empowerment to achieve a key outcome of reducing acute hospitalisation and avoidable morbidity. The top seven percent of adults at risk of hospital admission within the next six months are identified using a risk stratification algorithm. In addition to this, at-risk people are identified through clinical judgment and escalation triggers. Each person within the cohort has a designated Care Plan Coordinator, mostly primary care nurses. These coordinators are responsible for the initial patient assessment during which a validated self-management questionnaire is used to develop an annual “Year of Care” plan in partnership with the patient. A team-based approach is central to the HCH programme. For the most complex individuals, this includes input from a multi-disciplinary team, consisting of social workers, clinical pharmacists, physiotherapists, community-based nurses, and other kinds of service providers.
HCH was rolled out across Compass Health PHO in staged tranches beginning July 2016, with 26 out of 60 practices currently in the programme. This represents 188,252 enrolled patients, of which at least 3,760 will have completed a Year of Care plan. Data are collected for external reporting to the regional District Health Board (DHB) every two months. Data are also collected to inform practices of their progress against programme requirements over time. In July 2016, an evaluation of the programme was carried out by an independent Crown entity, which found that the HCH model, delivered in primary care, resulted in a statistically significant reduction in Emergency Department admissions.
HCH emphasizes the use of an extended primary care team, including the roles of primary care practice assistants and clinical pharmacists. A care coordinator identifies which clinical providers (including those employed by other agencies) should be involved in a multi-disciplinary meeting held at the general practitioner (GP) practice.
The program provides training to patients in shared decision-making processes as well as nurse-run self-management courses. Patients are provided with a portal that allows them to engage with their clinical provider, see clinical notes and book appointments. Patients are engaged in care planning and defining their goals. The program is developing shared group medical consultations with a facilitator and a GP. Caregivers are invited to participate in developing the Year of Care plan. Caregiver engagement has been identified as an area that needs improvement, and HCH is exploring the approach of using health coaches to help support this activity.
A group that includes representatives from the Primary Health Organization (PHOs), the DHB, clinicians, and managerial staff meet monthly to review progress and assess achievement of quarterly and annual plans. A national HCH collaborative brings together local teams that are implementing this care model. This unusual structure bridges local, regional, and national funders and providers.
GP practices that join HCH receive per capita funding, with the funding jointly provided by their PHO and the DHB. In addition to the per capita payments, practices receive start-up funding to provide support for the change-management process. Lastly, GP practices receive funding as an incentive to prevent emergency department admissions.