13 April 2018

Why changing the GP model is worth the effort

Patients TheHill

Sydney GPs shifting to a new integrative care model are reporting better morale, happier patients, and some uncertainty about investment returns.

The burden on general practices adopting the “patient-centred medical home” (PCMH) model is a heavy one, according to a new report from the WentWest Primary Health Network. 

Transition costs at five western Sydney practices were estimated at $1.6 million over three years – though all five practices indicated additional plans to invest in staff and equipment, depending on profitability.

The practices anticipated a need to invest in reconfiguring consulting rooms, workflow changes, hiring extra staff and insurance.

The research included interviews to identify barriers to the patient-centred medical home model.  For this purpose, it targeted a range of practices with varying degrees of capacity for change.

WentWest CEO Walter Kmet said the report was one of the few significant research efforts on primary care in the past year and showed the value of the model.

“The $100,000 we are talking about (annual start-up costs per practice) is a small amount of money relative to the whole health economy,” he told The Medical Republic.  

If rolled out to the western Sydney region’s some 350 practices, the cost would come to some $40 million, he said.

“We need, as a profession and an industry, for the government to invest more in patient-centred medical-home principles, because they do work,” he said.

Patients at medical-home practices were found to be “happier and enabled to manage better because they were more engaged with their care”, Mr Kmet added. 

About 60 western Sydney practices are taking part in a state-funded integrative care pilot, using a variety of elements to target chronic disease and linkage between primary care and the hospital system. 

Another 22 practices have joined the federal government’s Health Care Home pilot program. 

The research team, led by University of Western Sydney Professor Jenny Reath, interviewed 35 practice principals, GPs, nurses and managers from a range of practice types.

Some interviewees from non-PCMH practices “doubted the value” of the team-based medical-home approach and had concerns about the government’s agenda and GP work burdens, the report said.

But others, involved in the program, credited the PCMH model with bringing “improved health, enhanced patient and care-provider satisfaction and health system cost-efficiencies”.

“Interviewees from PCMH and integrative care practices described improved job satisfaction as a result of working together in a team to improve care, with staff upskilling, multi-skilling and career progression reported.”

Interviewees interested in taking up the PCMH model suggested feedback from early adopters would be useful.  

Several PCMH nurses and managers were unclear about what was expected of them and wanted more specific training. 

“I don’t even know what are these changes that we are supposed to implementing,” one practice nurse said.  

“I’d like a precise guideline of what it’s supposed to be, because I still can’t get in my head what exactly is this PCMH… Show me a video of a practice that has it in place working,” the nurse said.

 While IT was considered a key enabler for quality improvement, “challenges” with shared health records were a common complaint. Staff from all practice types also said older GPs needed help with computer technology.  

Fee-for-service remuneration was described as a barrier and a “poor fit” with PCMH care. Interviewees also considered the government’s Health Care Home remuneration inadequate. 

Of the five WentWest practices in the costings study, two were HCH trial participants, receiving bundled payments for enrolled patients with chronic disease.

The research identified large one-off expenses from time spent attending leadership and training sessions. 

The opportunity cost came to $385,000 across the five practices, for training provided mostly by the PHN or through online modules.  

One practice employing eight doctors, two nurses and five reception staff reckoned its cost at $127,000 for more than 950 staff-hours and lost income. Recurring costs, including time spent on case conferences and data reviews, came to $764,000 at the five practices, with the top estimate as high as $250,000.

Practice principals and managers who had embraced the new care model said they could not have done it without onsite support and assistance from the PHN. 

“The work of transformation is very hard,” Mr Kmet said. “It’s the work of transforming the sector we have now, which is a system designed for another age.

“There is a lot of evidence around how the journey we’ve been on in helping people move to a patient-centred medical home approach is valuable.”

Dr Walid Jammal, whose Bella Vista practice was part of the research, said GPs needed to be frank about the challenges.

“Transforming primary care is hard work and costly. But it has benefits, to the practice, the health system, and to patients,” he told The Medical Republic.

“We, as GPs, need to be transparent about this, as well as patient outcomes, so that our value can show and ultimately be rewarded. PCMH transformation is simply the right thing to do.”

Australia lags behind US jurisdictions and New Zealand in adopting the medical-home approach. 

In New Zealand, a GP-run practice network has recorded a plunge in hospital admissions among patients of its Health Care Home model.

Despite carrying the same name as the Australian government’s trial, the model is a “broader and radical redesign”, Helen Parker, general manager of the Pinnacle Inc network, told The Medical Republic.

“It covers a redesign of the whole practice population, regardless of whether they are ill or not,” Ms Parker said.

Data has shown that patients of its HCH practices were 16% less likely to be admitted to hospital and 8% less likely to present to an emergency department, she said. 

“It is a success not just in terms of hospital visits; that is not our main driver,” Parker said. “It’s a success in terms of being a much more convenient service for patients.”

Since Pinnacle kicked off the model in 2010, a total of 15 practices, with 101,000 patients, have made the transition.

Exhaustive data collection allowed comparisons of practices’ performance and outputs on a range of indicators, Ms Parker said.

It includes GP consultation types and rates, ethnicity and demographic data, email consults, and activity through patient portals where patients can check health records.

The group also collects the outcomes of GP triage consults, and ED presentation and hospitalisation information.

“We have yet to do analysis as to why (hospital admissions are down). But we can see that at the Health Care Home practices the GPs and nurses see more patients,” Ms Parker said.

“We know that one-third to 50% of patients who ring for a same-day appointment don’t need to come in. The GP can manage them over the phone.

“This saves the face-to-face appointments for the people who need them most and gets the practice away from being a mini ED service where it’s first in first served, regardless of what they need.”

The non-profit network is supporting practices and primary care organisations around New Zealand to roll out the model and sharing its expertise with Australian groups.