Person-centred medical care

We are fortunate to have many world-class health services in our region, but there remain substantial pockets where even access to basic health services is limited. Sometimes, available services are still poorly coordinated. This makes the health system harder to navigate and means some people miss out on receiving the care they need.

Our role is to improve coordination and communication between existing services, encourage and support new and expanded services in areas of need, and recast the health system to be centred on the needs of the person, rather than the requirements of health services.

All levels of government, as well as many large health organisations, are working to improve the health system. There is a strong focus on the importance of the primary health sector in supporting healthier lifestyles and meeting challenges such as rising rates of chronic disease and an ageing population.

Person-centred medical care is key to current reform efforts. The aim is to improve individual and community health outcomes by meeting each person’s needs and preferences with better services, and better coordination of services.

The Person-Centred Medical Home model

A Person-Centred Medical Home is a health entity such as a general practice, community health centre or Aboriginal community-controlled health organisation that strives to deliver integrated care of the highest quality based on people’s unique needs.

This is achieved through an evidence-based, coordinated, multi-disciplinary model of care that aims to improve efficiencies and promote innovation in primary care services.

Person-centred, integrated health care is generally accepted as the best way forward for better primary health care. The Australian Government’s recent Health Care Homes program was a trial of one method of delivering this kind of care.

While North Western Melbourne Primary Health Network (NWMPHN) was not part of this trial, we are already supporting general practice to build capacity to adopt the principles of a Person-Centred Medical model. This includes through a self-assessment tool and quality improvement activities and support, described in more detail below.

What are the key features of a Person-Centred Medical Home?

Central coordination of patient care

The care team support integrated patient care across the whole health care system through shared information and care planning. If a patient is referred to a specialist, the care team follows up to make sure it’s across all aspects of the patient’s ongoing care, keeping track of results to support the patient fully.

Customised shared care plan

The care team and the patient develop a customised, shared care plan. This includes setting patient-centred goals, developing care strategies to improve health, and identifying local care providers to best meet the patient’s needs.

Patient-team partnership

The patient, the patient’s family and the care team partner motivate the patient to increase their knowledge, skills and confidence to manage their health. New technology may be used to further assist patients in convenient ways.

Better access

During the day, patients can communicate with their practice by phone, email or video-conferencing. Back-up available after-hours can include locums and online support.

Flexible, team-based care

Practice teams share the care of a patient. Responsibilities – not tasks – are reallocated and all team members work at the top of their scope of practice. This increases capacity and access.

Commitment to high-quality care

Care-givers rely on evidence-based patient health care pathways to plan and decide how to give each patient the best-quality service.

Data-driven improvements

The health care team and the patient collect and share data to measure health outcomes and improve performance.