Benefits for Health Professionals

The healthcare neighbourhood is essentially a well-integrated health system. It aims to deliver a better experience for clinicians and patients, better health outcomes, and better cost efficiency. (1)

Improving the clinician experience is an important lever to drive change in the healthcare system. The benefits of Patient Centred Medical Homes (PCMHs) and better integration of care for clinicians include:

• increased professional satisfaction
• fulfilling the goal of helping patients
• making clinical work easier
• delivering more efficient services.

Improved work experience for primary care clinicians

• Patients have more confidence in their care team when the team works well together, and when they can appreciate the different members' complementary roles within a multidisciplinary team.
• In a PCMH, the patient and clinicians are confident they are working on agreed health priorities.
• Patients feel their preferences have truly been heard, and tend to be more engaged in self-care as a result.
• Patients are better at looking after themselves and following healthcare advice because they have received better self-care training.
• Clinicians have the information they need from other care providers, when they need it.
• Information technology and funding systems support more discussions and collaboration between clinicians for complex cases.
• Clinicians have easy, rapid access to specialist advice as they need it, reducing the need for outside referrals.
• Clinicians know how their service is being perceived, thanks to regular use of patient feedback systems; they can make improvements if feedback suggests it is needed.
• There is a culture of quality improvement, and clinicians are supported to test ideas to improve service.
• Clinicians are clear about their role in a patient’s care, what they should focus on, and what others will cover.
• Clinicians are supported to make the clinical team work well, and to ensure that clinicians outside the team are involved in good transitions of care for patients.
• Clinicians work in a system where high quality work can be identified in quality improvement data.
• Patients with long-term conditions that require monitoring and review come to planned review appointments. These appointments efficiently cover the bio-psycho-social elements of their health and optimise Medicare Benefits Schedule payments.
• Patients who struggle to coordinate their own care well, or those at risk on long waiting lists, are supported by care coordinators whose role is also to help different services work more efficiently together.

Benefits for practice staff

• All staff are encouraged to build their skills and knowledge, which leads to more interesting, challenging and valuable work.
• Clerical staff in the practice are more involved as part of the team. This improves morale because all staff make a difference to patients' wellbeing. This involvement also removes any 'us and them' mentality between the clinicians and office staff.

Benefits for private and public-sector specialists and allied health clinicians

• Clinicians see the right patient at right time. It is more efficient if a specialised healthcare provider sees patients well selected to match services provided. An integrated health system built around strong PCMHs increases the likelihood that patients will receive the right services at the right time.
• There is clarity on roles and responsibilities, due to better transfer of clinical information, and better use of collaboration tools and processes.
• Care is collaborative. Through its role, which includes care coordination, the PCMH facilitates better collaborative care, inclusive of the patient's input.
• People receive the right information at the right time. Each element of the Healthcare Neighbourhood shares responsibility for helping ensure other elements have the information they need, when they need it, to deliver their particular services.
• Transitions of care are safely made. Clearer understanding of roles and capabilities, combined with clear understanding of each clinician’s role in supporting integration throughout the healthcare neighbourhood, supports safe care transitions. The core PCMH team never ceases to have some responsibility for the patient. When the patient is in hospital, for example, the PCMH team remains part of their clinical team (hospital in-reach). This makes the PCMH team well prepared to support the patient's transition out of hospital.
• An enduring, core, primary-care clinical team ensures the specialised services make sense in overall patient care planning, and support patient preferences.
• Care coordination helps smooth out logistics and timeliness of services, and also helps services work together more effectively.
• Emphasis on patient-reported experience and outcomes, and patient input into service governance, enhances quality and ultimately value.
• Emphasis on self-care makes effective use of this often-untapped resource in healthcare.

Health system benefits

• reduced emergency department visits
• reduced hospitalisations
• reduced hospital readmissions
• reduced inappropriate healthcare interventions
• reduced duplication of services
• care better aligned to patient and family needs
• decreased total health spending
• a healthier, more supported population.⁽²⁾

The above benefits notwithstanding, clinicians note that barriers to change and potential negative impacts must also be considered.

• Disruption and change may add to stress and uncertainty.
• Not all steps in changing service models and system reform work out well; some changes may have a net negative impact, until corrected.
• System reform has elements of risk; health professionals are often quite risk-averse.
• System change can be a stressful experience if one's ability to influence it is limited or feels limited.

Nevertheless, across the world, there is growing emphasis on making health systems more integrated and efficient. Australia is also following this trend; change and reform will be an ongoing part of healthcare life here. The PCMH model, embedded in a strong healthcare neighbourhood, has proven to be an effective one for providing a strong, integrated health system.

References

1. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine 2014; 12:573-576.
2. Patient-Centered Primary Care Collaborative. The patient-centered medical home’s impact on cost and quality [Internet]. Washington: Patient-Centered Primary Care Collaborative; 2016 [cited March 2017]. Available from: http://fmahealth.org/sites/default/files/2015_ANNUAL_EVIDENCE_REPORT.pdf