PCMH models of care

In 2017-18 the Patient Centred Medical Home Innovation Project (PCMH IP) supported practices to develop and implement their own ideas for service improvement. Through this project local practices documented their models of care.

To support ongoing capacity building across our region, these models of care have been shared below for other practices wishing to implement new service models:

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BONE HEALTH GROUP CLINIC

Marima Medical Clinic (Goulburn) assessed osteoporosis as a chronic disease with a plan to reduce hospital admissions from preventable fractures and other complications.

Osteoporosis is a rarely identified chronic condition with two out of three Australians aged over 50 years having osteoporosis and osteopenia. 

See model here

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DIABETES MANAGEMENT IN GENERAL PRACTICE

Lakeside Medical Practice (Warilla) implemented a nurse-led clinic to improve the level of care provided to diabetes patients through clinical review.

Many patients do not present frequently enough for proper management of their diabetes so this project enabled more focused review and discussion between GP and patient. 

See model here

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RESPIRATORY DISEASE MANAGEMENT CLINIC

Dr Chandrans Surgery (Albion Park) developed a nurse-led respiratory disease management clinic to assist patients in better managing asthma and COPD, especially in the lead-up to winter. 

See model here

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RESPIRATORY EDUCATORS IN GENERAL PRACTICE

Moss Street Medical Practice (Nowra) piloted an integrated care approach for patients with chronic respiratory disease, given that hospitalisation rates amongst people living with COPD in the Shoalhaven are estimated significantly higher than the NSW state average rates. 

See model here

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WEIGHT MANAGEMENT IN GENERAL PRACTICE

Bulli Medical Practice implemented a nurse-led weight management clinic.

Eligible patients had the opportunity to work with their doctor to reduce their weight and therefore improve their overall health and chronic disease management.

By making the program nurse-led, it freed up doctors to see more acutely ill patients whilst still contributing to the management of these patients with chronic illnesses. 

See model here

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SPECIALIST TELEHEALTH HUB

Jindabyne Medical Practice implemented a system using up-to-date secure technology to provide our local families’ access to top pediatricians in Jindabyne.

See model here

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CARE TRANSITION

Sharp Street Surgery implemented a telehealth support service for patients discharged from hospital. Patients often get discharged from hospital with only a few days’ supply of newly started medication. At risk patients like elderly patients, or patients with disability are often worse affected by multiple comorbidity.

The project aimed to check on patient wellbeing, review any new and existing medications; and confirm or arrange appointments and referrals. This support has the potential to facilitate faster return to optimal health and reduce the chance of hospital readmission.

See model here

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PSYCHO-SOCIAL EDUCATION ON MENTAL HEALTH

Russell Vale Family Medical and Acupuncture Practice introduced bilingual trauma counselling for local Syrian refugee families with complex needs as a result of grief and loss, helplessness and fear from war and impacts of the refugee experience.

The project aimed to improve continuity of care through better engagement and understanding of the patient.

See model here

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PHARMACISTS IN GENERAL PRACTICE

Market Street Medical Practice (Wollongong) included a consultant pharmacist and credentialed diabetes educator to focus on multidisciplinary care around medication review, especially for older patients who are often on a number of medications.

By focusing on de-prescribing and drug optimisation, this project aimed to reduce the number of potentially preventable hospitalisations.

See model here

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ENHANCED ANNUAL CYCLE OF CARE FOR HIGH RISK DIABETIC PATIENTS

Illawarra Family and Medical Centre (Wollongong) enhanced its nurse-led diabetes management program involving the creation of a ‘high risk’ patient stream.

Patients with high risk diabetes are at greater risk of developing co-morbidities than those with their condition under control. These patients are also at greater risk of poor health, increased hopitalisations and generally a poorer quality of life. This project targeted these patients. 

See model here