“One in five Australians now have multiple chronic conditions. This means they are living with any mix of heart disease, diabetes, cancer, mental health issues, eye disease, respiratory problems, arthritis and more.

About 65,000 Australians will participate in initial two-year trials of Health Care Homes in up to 200 medical practices from 1 July 2017. An extra $21 million will be committed to support the rollout of trials, starting 1 July 2016. The remaining balance of the package is expected to be cost neutral, in line with PHCAG recommendations, with further evaluation to continue ahead of a national rollout.”

Minister for Health the Hon. Sussan Ley Press Release Health Care Homes to keep chronically-ill out-of-hospital

“The Health Care Home will also focus on educating patients in regional and remote communities on their health conditions to provide them with the knowledge, skills and confidence to manage their day to day care. Better education will also enable patients to be more active participants in decisions made about the care that they receive.

Today’s announcement reflects the Turnbull Government’s commitment to investment in regional communities and to work with health providers and the public to improve health outcomes for all Australians.”

Minister for Rural Health The Hon. Senator Fiona Nash MEDIA RELEASE ( see second below ) Rural & Remote communities to get better chronic care

Please note the NACCHO policy team is currently reviewing the implications for our Aboriginal Community Controlled Health sector and will be issuing  a position paper shortly

Download the Better Outcomes for people with Chronic and Complex Conditions here

 Health Care Homes to keep chronically-ill out-of-hospital-Ley

For the first time, Australians living with multiple complex and chronic illnesses will be able to officially enrol with their local GP to have all of their conditions and health care needs conveniently managed in one place, as part of the Turnbull Government’s revolutionary Healthier Medicare reform package, announced today.

One in five Australians now have multiple chronic conditions. This means they are living with any mix of heart disease, diabetes, cancer, mental health issues, eye disease, respiratory problems, arthritis and more.

Yet, Australians who are very high users of our health system saw an average of five different GPs in a year – triple those who are low users of our health system.

This fragmentation in the health system has led to a number of adverse and preventable issues for chronically-ill patients, as found by the Turnbull Government’s clinician-led Primary Health Care Advisory Group (PHCAG):

“Most patients with multiple chronic conditions receive treatment from many health providers: most of them working in different locations, and often working in different parts of the health system. This leads to concern regarding the quality and safety of patient care.”

“Every 2-3 hours in Australia there is an amputation that could have been prevented with better management of diabetes.”

To combat this, the Turnbull Government will support the establishment of ‘Health Care Homes’ in General Practices or primary health care services that will design tailored care plans (in consultation with these patients) that not only outline the health services they need, but coordinate them as well.

This means patients will be supported with access to coordinated medical, allied health and out-of-hospital services, regardless of whether they are provided by Medicare, state and local governments, the community sector or the multitude of other sources currently fragmenting the system.

This is supported by the recommendations of PHCAG, chaired by immediate past Australian Medical Association President and GP Dr Steve Hambleton:

“Personalised care is essential to addressing individuals’ full range of needs.”

“Central to the reform is the establishment of Health Care Homes, which provide continuity of care, coordinated services and a team based approach according to the needs and wishes of the patient. Our new approach offers an opportunity to improve and modernise primary health care and maximise the role of patients as partners in their care. It represents innovative, evidence-based best practice that harnesses the opportunity of digital health care. Importantly, it has strong support from consumers and healthcare professionals.”

The new Health Care Homes model will also be supported by a more-flexible payment structure allowing health practitioners to focus on quality improvement without the rigid constraints of Medicare’s current fee-for-service model.

Primary Health Networks will have an important role in supporting Health Care Homes through the establishment and promotion of local clinical health pathways and through education and training support.

About 65,000 Australians will participate in initial two-year trials of Health Care Homes in up to 200 medical practices from 1 July 2017.

An extra $21 million will be committed to support the rollout of trials, starting 1 July 2016. The remaining balance of the package is expected to be cost neutral, in line with PHCAG recommendations, with further evaluation to continue ahead of a national rollout.

Our Healthier Medicare reforms will truly transform the way primary care is delivered and funded in this country by giving GPs the flexibility and tools they need to work with a patient’s full health care team to keep them happier, healthier and out-of-hospital.

“Reforms being considered to aged care, mental health and private health insurance, as well as review of key health care enablers such as digital health and the MBS, are designed to improve health system integration and highlight a shift in the service delivery paradigm towards better integrated, more regionally relevant, patient-centred care.”

Key features of Health Care Homes, as recommended by PHCAG and adopted by the Turnbull Government through its Healthier Medicare package of reforms, include:

•  Voluntary patient enrolment with a practice or health care provider to provide a clinical ‘home-base’ for the coordination, management and ongoing support of patient care. This includes the development of an individualised care plan for patients tailored to their specific conditions and health care needs.
•  Patients, families and their carers as partners in their care where patients are motivated to maximise their knowledge, skills and confidence to manage their health, aided by technology and with the support of a health care team.
•  Patients have enhanced access to care provided by their Health Care Home in-hours, which may include support by telephone, email or videoconferencing, and effective access to after-hours advice or care.
•  Patients nominate a preferred clinician who is aware of their problems, priorities and wishes, and is responsible for their care coordination.
•  Flexible service delivery and team based care that supports integrated patient care across the continuum of the health system through shared information and care planning.
•  A commitment to care which is of high quality and is safe. Care planning and clinical decisions are guided by evidence-based patient health care pathways, appropriate to the patient’s needs.
•  Data collection and sharing by patients and their health care teams to measure patient health outcomes and improve performance.

Case study – Option 1

The Health Care Home – Patient-Focused Care

Michael is a 77 year old retired wood turner whose health is failing. He lives in the family home alone having lost his wife and his adult children have moved on. He has multiple medical problems including: depression; heart disease; osteoporosis; diabetes; cataracts; and chronic obstructive pulmonary disease. Michael is not looking after himself, he is eating poorly, has had multiple recent hospital admissions, and he is taking a number of medications that are causing serious side-affects.

The GP in Michael’s Health Care Home involves the local care team to help manage his issues with the focus being on making Michael’s life easier and safer. The GP develops a chronic disease management plan around Michael’s preference to continue to live independently. He is referred to the visiting dietician, diabetic educator and physiotherapist to enable him to better manage his medical care. A community pharmacist is asked to develop a medication management plan.

The Health Care Home also coordinates social services offered and funded by different Government and community programmes to improve Michael’s quality of life and provide the support he needs to continue to live independently. These include: organising the regional aged care assessment service to visit Michael in his home to assess his needs and to determine what type of home care package would suit him best; engaging a cleaner; finding a way to address home modifications recommended by a hospital based Occupational Therapist; and organising Meals on Wheels to deliver food.

As a result of this coordinated care Michael’s nutritional status improves and he feels stronger, more informed, better supported and more engaged with his care team. His GP and community pharmacist together rationalise the timing of use and the range of his medications. This improves his understanding of them and leads to increased compliance while minimising their side effects.

The future for Michael is looking much brighter as he regains autonomy.

Case study – Option 2

The Health Care Home – Patient-Focused Care

Derek is a 74-year-old retired coal miner who now lives on his own in the community after losing his partner. Derek has multiple health problems (including heart disease, osteoarthritis, poor hearing, and Type 2 Diabetes), and was recently hospitalised.

Derek saw his GP because he was having trouble breathing after a cold. Derek also told his GP he was not eating well and found it difficult to do the things he used to do because of increased pain in his left hip. The GP and health care team developed a care plan with Derek around his goals to remain independent and active. Derek was started on treatment for his breathing problems and was referred to a physiotherapist, dietician and psychologist.

Knowing that Derek had private health insurance, with Derek’s permission the practice contacted his private health insurer and arranged for Derek to register for an osteoarthritis management program being delivered by his insurer.

Derek now feels more confident that he will be able to better manage his health into the future.

Rural & Remote communities to get better chronic care

The Turnbull Government’s revolutionary Healthier Medicare reform package, announced today, will provide people living with chronic and complex conditions in rural and remote communities with care better tailored to their needs.

Today’s announcement is the Turnbull Government’s response to the Primary Health Care Advisory Group’s (PHCAG) review of the management of chronic and complex conditions by Australia’s primary health care system.

In their report to the Government, Better Outcomes for People with Chronic and Complex Health Conditions, PHCAG noted:

“Coordination of care remains a challenge in many rural practices. Increasing care continuity for high needs patients through enrolment in the Health Care Home and increasing communications between health care providers through more effective use of digital health records holds considerable promise for the delivery of care in rural communities.”

Accordingly, the Government has today announced the adoption of the Health Care Home model of care to tackle the growing challenge posed by chronic and complex conditions. Health Care Homes will help patients to find and access the health care services that they need, when they need them.

They will also simplify a chronically ill patient’s care by allowing them to nominate one general practice as their ‘home base’ for the coordination of their care needs on an ongoing basis.

The Health Care Home will also focus on educating patients in regional and remote communities on their health conditions to provide them with the knowledge, skills and confidence to manage their day to day care. Better education will also enable patients to be more active participants in decisions made about the care that they receive.

Many aspects of the Health Care Home model are already in place in rural and remote general practices and community controlled health services across the country to help bridge the unique service gaps they face every day. This initiative will support them to formalise this model of care and build on these innovative local solutions.

While people living in regional and remote communities have a higher burden of disease they generally have poorer access to health services. In 2013-14, nearly one in three people living in outer regional, remote or very remote areas waited longer than they felt acceptable to get an appointment with a GP compared with just over one in five in major cities. These patients were more likely than people living in major cities to attend an emergency department to receive care as a consequence of not being able to access a GP when required.

To improve access to health services for people with chronic conditions in regional communities, the Government has unveiled flexible funding arrangements that make it possible for patients to connect with their GP and health care team in ways not previously available through Medicare.

Flexible funding will also support health providers to adopt new health care innovations such as the use of remote monitoring devices to stay on top of a patient’s condition.

The changes announced today are part of a broader strategic approach to health care reform designed to tailor health care services to the needs of local populations and to redress inequities in care faced by regional and remote communities.

On 1 July 2015, the Government established Primary Healthcare Networks (PHN) to work with local communities to identify gaps in health care services. Flexible funding provided to PHNs enables them to commission services to address these unmet service needs.

The Government has also committed to expanding the rural health care workforce through the introduction of the Integrated Rural Training Pipeline (IRTP) measure and the creation of an additional 300 training positions under the Australian General Practice Training Programme.

Today’s announcement reflects the Turnbull Government’s commitment to investment in regional communities and to work with health providers and the public to improve health outcomes for all Australians.