Data holds the key to patient-centred care

The growing burden of managing chronic diseases will require practices to redesign their workflows

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A pioneer of the American “patient-centred” primary care model, which has inspired Australia’s Health Care Home trials, says better health outcomes were visible within a year.

Dr Kirsten Meisinger, of Boston’s Cambridge Health Alliance, was in Sydney last week advising general practices on how to make the transition to a data-rich, team-based care model with workflow designed around patients.

The key ingredients were multidisciplinary teamwork, a deep understanding of patients’ needs and making the most of high-quality data. These elements made healthcare access easier for patients and allowed doctors to focus on medicine, Dr Meisinger said.

“An essential aspect of the patient-centred medical home is caring for patients when they are not in front of you and caring for patients across their lifetime,” she said.

“The way we do that is that we have patients choose their GP.  They can change any time they want, but they have – for the time they have chosen (me) as a GP –  decided that I am responsible for their health indices, their health outcomes.  And I feel that responsibility quite heavily.

“That means that if you are due for a mammogram, you are not required to come in for a visit. I can ask a team member to reach out to you and set up an appointment for that screening.

“So I spend my time doing what I was trained to do. I treat, I diagnose, I educate.  I am not actually ordering mammograms. My opinion is not required. It’s not my opinion whether or not you need a screening test. It’s science that informs us.”

Across the board, practices that adopted the model had reported improved outcomes and better patient engagement, for which Dr Meisinger partly credits the role of practice nurses.  “Add the nurse and it’s like you are adding another superpower to the team.  Add the pharmacist and you have two superpowers,” Dr Meisinger told TMR.

“Within one year of adding those visits we had amazing results on things like blood-sugar control.  We actually found in the first year more disease than we’d ever identified before, but that’s a good thing.”

Practice managers were vital in playing a coordinating role, she added.

“The practice manager is absolutely the centre of this transformation, in my experience.

“They are marvellous, because they understand.  They have always had to look at the practice from the patients’ viewpoint and now this gives them a framework to take that incredible knowledge and wealth of experience and move it along a certain pathway.”

Dr Meisinger has been working for three years with the western Sydney primary health network WentWest, consulting with the PHN and affiliated practices.

Eight practices in the western Sydney area had taken a “deep dive” to explore the data-driven team-based care model in a program under way since 2013, WentWest CEO Walter Kmet said.

“We are looking for a continual improvement in primary care capacity and capability. Reinforcing the principles of the patient-centred medical home is one of the ways we can do that,” he said.

While the PHN could offer support in coordinating services and funding of pharmacists, for example, GPs needed to take leadership in developing a better approach to deal with the growing burdens of chronic disease in the community.

“The profession itself needs to find ways to respond to what are clearly changing and increasing demands on the health system.  I think the more we can invest in GPs and primary care practices right across the system to do that, the better the system will be,” Mr Kmet said.

One challenge was to shift away from fee-for-service and find a payment method that will reimburse better quality of care for a population that needs longer-term  continuity of care, rather than short-term intervention.

“We want to make sure the enablers around patient-centred medical homes are right.  One of them, of course,  is payment – making sure we reimburse for value, not volume.

“But there are other areas in which we can support practices. We have been supporting practices though quality improvement work, and investing in team- care arrangements, like placing pharmacists in general practices and chronic disease nurses where we can add them to the team.”

Dr Meisinger said her advice for Australian GPs interested in taking up the model was simple.

“Start by looking at your practice, by using data.  The fundamental thing about taking care of patients when they are not in front of you is that you have to know who they are, whether they have met their health goals or not, and what is the next best step for them. All that is data-based.”

Practices that become Health Care Homes should identify the patients they know would be eligible and find opportunities to engage them and start them on a new health journey in ways that would be financially sustainable and worked for GPs and the staff, she said.