A presentation by Paresh Dawda, Andrew Knight and Leanne Well at the BMJ/IHI International Forum on Quality and Safety in Healthcare (London 2017)

1. The patient-centred health care home as an
enabler to improving transitions of care
Andrew Knight - Paresh Dawda
By Video: Leanne Wells

2. Register of Interest
Staff Specialist and Conjoint
Senior Lecturer UNSW and
Fairfield GP Unit
Chair Nepean Blue Mountains
PHN
Primary Care Committee,
Australian Commission for
Quality and Safety in Healthcare
Director NPS Medicinewise
• Regional Medical Director, Ochre Health
• Regional Medical Director, National Home
Doctor Service
• Chair, Clinical Review Committee, Canberra
Hospital
• GP Specialist Consultant, NSW Agency for
Clinical Innovation
• Primary Care Committee, Australian
Commission for Quality and Safety
• Quality and Safety Board Advisory
Committee of Australian Digital Agency
• Quality Care, RCGP
• Agency for Clinical Innovation
• ACT Clinical Council
• Healthcare Homes, GET Group Member,
Australian Department of Health
• Honorary Associate Professor, ANU and
University of Canberra
Paresh was employed by ANU when he conducted an academic
review of transitions of care.
This presentation is not supported by any organisation, and
views presented are his opinion informed from multiple
perspectives
@pareshdawda
Andrew is a staff specialist in the NSW health system and is
supported to attend this conference.
This presentation is not supported by any organisation, and
views presented are his informed from multiple perspectives
awknight@aapt.net.au

3. Transitions of Care
Introduction
Transitions of care
– the what and
questions about the
how?
Primary care and
the medical home -
hopes for a new
how?
Questions and
discussion

5. Clinical aspects of care transfer
PLUS
Patient’s needs, preferences,
experiences
• Clinical information
• Physical and mental functional status
of patient
• Suitability of patient’s home
environment
• Availability of carer, family, support
system
• Ability to obtain medicines, needed
healthcare & social services /
availability of transportation

6. • Clinical outcomes
• Increase in mortality
• Increase in morbidity (temporary or permanent injury or disability)
• Increase in adverse events
• Emotional and physical pain and suffering for consumers, carers and
families
• Waste
• Additional primary health care (PHC) or emergency department (ED)
visits
• Additional or duplicated tests
• Preventable readmissions to hospital
• Additional costs to consumer, family, health system and community
• Experience
• High level of consumer and provider dissatisfaction with coordination
of care across primary care / hospital interface.
• Delays to appropriate treatment and community supports
The evidence base for the impact of these problems is variable. There is little quantitative evidence for the impact of problems
specifically due to clinical handover or other specific components of transition of care as most of the research does not focus
measure this directly.

7. Phil
• Man in his 50s
• Aboriginal Origin, lives with partner, no children
• General fit and well
• Has a role as an administrator in the public service
• Had intermittent abdominal pain over a few months
• Diagnosed with cholecystitis
• Admitted for elective procedure

8. Jim
• Man in his 80s
• Has COPD, IHD, CCF, OA
• Multiple medications
• Mobility: 4 WW
• Lives at home with wife (has her own health problems)
• Admitted with exacerbation of COPD and community
acquired pneumonia

9. • Betty, in her 70s
• Lived with husband, he was principle carer
• Previous history: osteoarthritis, some SOB, possible
memory impairment (undiagnosed-husband put it down
to ageing)
• Admitted with acute delirium and a UTI
• UTI treated – Geriatrician assessment – probable
Alzheimer's disease
• Functional decline with this admission
• Being discharged to an aged care facility

10. What are the different
transitions of care issues
raised by each scenario?

11. If any one of these were a
patient in your health system
what interventions would they
have to support a more
effective transition of care?

12. How reliably are those
interventions delivered?

13. How do you measure
the impact of transitions
of care?

14. Discuss
(10 mins)
• What are the different transitions
of care issues raised by each
scenario?
• If any one of these were a patient
in your health system what
interventions would they have to
support a more effective transition
of care?
• How reliably are those
interventions delivered?
• How do you measure the impact
of transitions of care?

15. Interventions

16. Programs
http://bit.ly/ToCprograms

17. Metrics (Research)
healthcare
utilisation
continuity of
care
Patient/carer
status
errors/adverse
events/near
misses

18. Measures
• Structure
– Accountable provider at all points of care transitions
– A tool for plan of care
– IM&T – intergrated and inter-operable
• Process
– Care planning inc ACP
– Mediation reconciliation
– Test tracking
– Referral tracking
– Admission and discharge planning
– Appointment tracking
– End of life decision making
• Information transfer/Communication
– Timeliness and completeness of information
– Protocol of shared accountability
• Patient and family education/engagement
– Patient and/or family preparation for transfer
– Patient and/or family education for self-care
– Patient and/or family agreement with the care transition (active participation in
making informed decisions)
– Appropriate communication with a patient with limited English proficiency and
health literacy
• Outcomes
– Patient’s and/or family’s experience and satisfaction with care received.
– Provider’s experience and satisfaction with the quality of interaction and
collaboration among providers involved in care transitions.
– Health care utilization and costs (e.g., readmissions, etc.).
– Health outcomes consistent with patient’s wishes (e.g., functional status, clinical
status, medical errors, and continuity of care).
Source: Transitions of care measures
http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf

19. Structure
Accountable provider at all
points of care transitions
A tool for plan of care
IM&T – intergrated and
inter-operable
Process
Care planning inc ACP
Mediation reconciliation
Test tracking
Referral tracking
Admission and discharge
planning
Appointment tracking
End of life decision
making
Information
transfer/Communication
Timeliness and
completeness of
information
Protocol of shared
accountability
Patient and family
education/engagement
Patient and/or family
preparation for transfer
Patient and/or family
education for self-care
Patient and/or family
agreement with the care
transition (active
participation in making
informed decisions)
Appropriate
communication with a
patient with limited English
proficiency and health
literacy
Outcomes
Patient’s and/or family’s
experience and
satisfaction with care
received.
Provider’s experience and
satisfaction with the
quality of interaction and
collaboration among
providers involved in care
transitions
Health care utilization and
costs (e.g., readmissions,
etc.)
Health outcomes
consistent with patient’s
wishes (e.g., functional
status, clinical status,
medical errors, and
continuity of care)
Source: Transitions of care measures
http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf

20. The Key Steps
20

21. The Key Steps
21
• There are a number of predictive risk tools
e.g. LACE, HARP, PARR, 8Ps
• The evidence for their utility is variable and depends on the dataset used
• “Most current readmission risk prediction models perform poorly…but
in certain settings may prove useful”
• Importance of GP data as the denominator (population health
perspective)
• Incorporating functional and social variable improves discrimination
References:
Kansagara, D. et al. (2011) Risk prediction models for hospital readmission: a systematic review. Jama,
Lewis, G., Curry, N. & Bardsley, M. (2011) Choosing a predictive risk model: a guide for commissioners in England. London: The Nuffield Trust,
Wallace, E. et al. (2014) Risk prediction models to predict emergency hospital admission in community-dwelling adults: a systematic review. Medical care, 52, 751.
Billings, J. et al. (2013) Choosing a model to predict hospital admission: an observational study of new variants of predictive models for case finding. BMJ open, 3, e003352.
Billings, J. (2005) Predictive risk Project.

22. The Key Steps
22From: Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review
Ann Intern Med. 2013;158(5_Part_2):397-403. doi:10.7326/0003-4819-158-5-201303051-00006
• Medication reconciliation is widely recommended to avoid unintentional
discrepancies between patients’ medications across transitions in care.
• Medication reconciliation alone probably does not reduce postdischarge
hospital utilization within 30 days but may do so when bundled with other
interventions that improve discharge coordination.
• Pharmacists play a major role in most successful interventions.`

23. The Key Steps
23
Timely
Accurate
Content
discharge diagnosis, treatment received in hospital, results of
investigations and the follow- up required , pending diagnostics
Availability
Human factors - https://www.safetyandquality.gov.au/wp-content/uploads/2017/02/Guidelines-
on-screen-presentation-of-discharge-summaries.pdf
Wimsett, J., Harper, A. & Jones, P. (2014) Review article: Components of a good quality discharge summary: a systematic review. Emerg Med Australas, 26, 430-438.
Cummings, E.A. et al. (2010) A Structured Evidence-Based Literature Review on Discharge, Referral and Admission.

24. The Key Steps
24
• Under-utilised
• Needs to be personalised;
• Involvement is variable from passive participants to being
the key actor
• Key element is behaviour change – patient activation

25. Level 1
• Individuals tend to be passive and feel overwhelmed by managing their
own health. They may not understand their role in the care process.
Level 2
• Individuals may lack the knowledge and confidence to manage their
health.
Level 3
• Individuals appear to be taking action but may still lack the confidence
and skill to support their behaviours.
Level 4
• Individuals have adopted many of the behaviours needed to support
their health but may not be able to maintain them in the face of life
stressors.
Source: Hibbard, J. & Gilburt, H. (2014) Supporting people to manage their health. An introduction to patient activation. London: The King’s Fund,
Activation is developmental

26. Low activation signals problems (and opportunities)
26
Source: Hibbard. Available at http://www.ehcca.com/presentations/readsummit2/hibbard_2.pdf

27. Most activated are less likely to miss
medication doses
27Source: Hibbard. Available at http://www.ehcca.com/presentations/readsummit2/hibbard_2.pdf

28. The Key Steps
28

29. The Key Steps
29
36% of post discharge
interventions are not
completed

30. A High Level Transitional Care Process
30

31. Moving beyond readmission penalties: Creating an ideal process to improve transitional
care
Journal of Hospital Medicine
Volume 8, Issue 2, pages 102-109, 26 NOV 2012 DOI: 10.1002/jhm.1990
http://onlinelibrary.wiley.com/doi/10.1002/jhm.1990/full#jhm1990-fig-0001

32. Source: Burke et al. BMC Health Services Research 2014, 14:423 http://www.biomedcentral.com/1472-6963/14/423

33. Key Issues
• How to identify / target high risk patients?
• Who should be accountable for transition of care?
• Is there a role for a ‘transition of care’ structure e.g. transition care team
• How to best help carers / family to be effective advocates
• What levers will facilitate clinicians to take a more pro-active role
• Evaluating reliability in implementation of key elements and understanding
variations in capability, capacity.
33

34. Aims
1. The evidence for primary care
2. The Patient Centred Medical Home
3. The Patient Centred Health System

35. Primary Health Care
Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The
relationship between primary care, income inequality, and mortality in
US States, 1980-1995. The Journal of the American Board of Family
Practice /American Board of Family Practice. 2003;16(5):412-22.
Shi L, Macinko J, Starfield B, Xu J, Politzer R. Primary care, income
inequality, and stroke mortality in the United States: a longitudinal
analysis, 1985-1995. Stroke. 2003;34(8):1958-64.
Starfield B, Shi L. Policy relevant determinants of health: an
international perspective. Health Policy. 2002;60(3):201-18.
Macinko J, Starfield B, Shi L. The contribution of primary care systems
to health outcomes within Organization for Economic Cooperation and
Development (OECD) countries, 1970-1998. Health services research.
2003;38(3):831-65.
Starfield B, Shi L, Macinko J. Contribution of primary care to health
systems and health. Milbank Q. 2005;83(3):457-502.
USA
13 industrialised countries
18 OECD countries

36. Primary Health Care
Strong primary health care in a health system is
associated with
• reduced system costs
• better outcomes
• reduced health impacts of social inequalities
An increase of 1 primary care physician per 10000
US population associated with a 5.3% reduction in
average annual mortality.

37. Primary Health Care
2008 WHO Primary Care. Now more than ever
• Key strategy for addressing the rising burden of
chronic disease while containing costs
2016 WHO Framework for achieving people
centred integrated health services
• Building strong primary care-based systems to
ensure population reach and universal access,
…striving for quality improvement and safety

38. What is a Patient Centred Medical
Home?

39. Standards for Child Health
American Association of Pediatrics 1967
“For children with chronic diseases or disabling conditions, the lack of a
complete record and a ‘medical home’ is a major deterrent to adequate health
supervision. Wherever the child is cared for, the question should be asked,
‘Where is the child’s medical home?’ and any pertinent information should be
transmitted to that place” (pp 77-79).

40. The Patient Centred Medical Home
The 2007 “Joint Principles of the Patient Centred Medical Home”
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
Seven principles agreed by all primary care colleges in the US and ratified by 22 professional
organisations.
Agency for Health Care Quality and Research & PCPCC
http://www.pcpcc.org/about/medical-home http://pcmh.ahrq.gov/page/defining-pcmh
Five principles describing a medical home in the US context, built on the principles agreed by all
primary care colleges in 2007 and appear on US govt website.
Safety Net Medical Home Initiative
http://www.safetynetmedicalhome.org/change-concepts
Eight change ideas are less descriptive and more “how” to transform an organization to a
medical home
Australian Centre for the Medical Home
Eleven principles resulting from a consultation process which was deliberately inclusive to capture
all ideas relevant to the Australian expression of the medical home.
http://medicalhome.org.au/what-is-a-medical-home/
RACGP “what is general practice”
http://www.racgp.org.au/becomingagp/what-is-a-gp/what-is-general-practice/
This definition contains many elements of the others and additionally places general practice in
the context of the health system

41. The PCMH

42. The PCMH

43. The PCMH

44. The PCMH

45. Patient Centred
Comprehensive
Coordinated
Accessible
Quality and Safety
Accountable
Continuity

46. Patient Centred Care
A Medical Home partners with patients, carers,
and family to ensure cultural preferences and
values are respected. Patients receive the
education and support they need for shared
decision making and to manage their own
conditions to the extent they are able. Patients
have the opportunity to participate in the care
design of the medical home.

47. Comprehensive
The medical home team is responsible for the
range of each patient's physical and mental
healthcare needs - including prevention and
wellness, acute care and chronic care.
Care in the medical home is continuous - each
patient has an ongoing relationship with a
particular GP and the medical home team.

48. Coordinated
The medical home ensures each patient can access the
full team they need to manage their health, which
includes arranging and coordinating care with other
providers. This may sometimes include hospital inpatient
care.
The medical home ensures that each person experiences
integrated (joined-up) health care, in which there is
informational consistency between all team members
with clear roles, goals and communication pathways.
The medical home retains accountability for a patient's
care, even when that person is not standing in front of
them. It tries to ensure that each patient receives best
possible care from all members of their care team.

49. Accessible
In a medical home, patients can access care for
their acute or routine medical needs when
required. The medical home is also proactive in
managing chronic conditions
A medical home uses a range of communication
tools with patients, (face to
face/telephone/virtual)

50. Focus on Quality and Safety
A medical home has a system based approach to
make sure that each patient receives best practice
care. It has systems to improve patient safety.
A medical home is the curator of each person’s
medical history, and maintains accurate clinical
records.
It uses registers to monitor patient population
needs, and it measures performance for quality
improvement.

51. Evaluations
Agency for Healthcare Research and Quality 2014 Zutshi et al
Reviewed 498 articles 2000-10. 14 evaluations of 12 interventions. “mostly inconclusive results”
“found some favorable effects on quality of care, hospital and emergency department use, and
patient or caregiver experience, and a few unfavorable effects on costs.”
https://pcmh.ahrq.gov
Patient Centred Primary Care Collaborative 2016 The Patient-Centered Medical Home’s Impact on
Cost and Quality Annual review of evidence 2014/15
30 initiatives. 21/23 reported cost reductions
https://www.pcpcc.org
Sinaiko et al Health Affairs 36, no.3 (2017)
Metaanalysis of 11 major initiatives. Heterogeneity in outcomes. 1.5 percent reduction in the use of
specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2
percent reduction in total spending (excluding pharmacy spending)and a 1.4 percent increase in
breast cancer screening among highermorbidity patients.

52. Home

53. Home
White KL 1961

55. Home Medical Home

56. Home Medical Home Community Hospital
Medical NeighbourhoodPrimary Health Networks LHDs

57. Home Medical Home Community Hospital
Medical NeighbourhoodPrimary Health Networks LHDs The Person-
Centred
Health
System

58. Home Medical Home Community Hospital
Medical NeighbourhoodPrimary Health Networks LHDs The Person-
Centred
Health
System

59. Home Medical Home Community Hospital
Medical NeighbourhoodPrimary Health Networks LHDs General Practice: A
vision for what we can
be
Patients: A standard
to look for and
demand
Funders/Policy: A
model to design for
Specialists: A
definition of role

60. Bodenheimer T, Ghorob A, Willard-Grace R,
Grumbach K. The 10 building blocks
of high-performing primary care. Ann Fam
Med. 2014 Mar-Apr;12(2):166-71.

61. PCMH
Just a model
Measurement/accreditation
Within/without…easy to do the right thing
PHNs
Reviews
Begin with the end in mind…
awknight@aapt.net.au

62. North Coast PHN
Project Officer and Handbook
http://ncphn.org.au/medical-home/download-
handbook/
QI approach rather than accreditation
Collaboratives, Model for Improvement, Kaizen groups
– FUN…
Practices choose where they want to start
Not prescribing a sequence of steps.
Change facilitators support
No payments

63. Western Sydney PHN
Well developed program as part of NSW integration project
Building block approach
Practice champions
Strong investment including US visits
IT underpinnings including Linked EHR

64. Health Care Homes Trials
“A Health Care Home is a general practice or Aboriginal
Community Controlled Health Service (ACCHS) that
coordinates care for patients with chronic and complex
conditions”
Commencing July 2017 10/31 PHN regions
Focused on patients with chronic disease
200 practices 65000 patients
Bundled fee for service payments with organisational
development of practices to improve care for those with
complex and chronic conditions
http://www.health.gov.au/internet/main/publishing.nsf/content/health-care-homes

65. Moving beyond readmission penalties: Creating an ideal process to improve transitional care
Journal of Hospital Medicine
Volume 8, Issue 2, pages 102-109, 26 NOV 2012 DOI: 10.1002/jhm.1990
http://onlinelibrary.wiley.com/doi/10.1002/jhm.1990/full#jhm1990-fig-0001

66. Source: Burke et al. BMC Health Services Research 2014, 14:423 http://www.biomedcentral.com/1472-6963/14/423

67. The challenge!
We believe primary care needs to take responsibility
for transitions of care
What needs to
change for this
to be achieved?
Discuss 10 mins
Feedback 10 mins

69. Summary
• Effective transitions important for safety / quality
• Can be improved through:
– The right structure
• Role clarity
• Shared clinical practice guidelines and protocols
• Enablers
– The right process
• Individualised and stratified interventions
• Communication and working as one system
• Preparing patients and caregivers
• Culture is important
• Effective change management critical
69

70. Contact
awknight@aapt.net.au
dr.paresh.dawda@gmail.com
L.Wells@chf.org.au