186226 - Health Care Homes Module 8: Comprehensive and coordinated care
This module discusses the value of comprehensive and coordinated care in Health Care Homes in reducing care fragmentation. It focuses on tools and strategies to provide effective, comprehensive and coordinated care in the Health Care Home and the importance of GPs, nurses and the care team using an integrated communication model with patients and their care providers in the health care neighbourhood.
Relevance to General Practice
Health Care Homes is a model of care for general practices and Aboriginal Community Controlled Health services (ACCHS). A Health Care Home is an existing general practice or ACCHS that further commits to a systematic approach to chronic disease management in primary care. This approach supports accountability for ongoing high quality patient care. It uses an evidence-based, coordinated, multi-disciplinary model of care that aims to improve efficiencies and promote innovation in primary care services.
- Describe the relationship between comprehensive care and care coordination in the Health Care Home.
- Define roles of team members and responsibilities for care both within the Health Care Home and across the health care neighbourhood.
- Allocate time and a structure for GPs, nurses and the care team to create appropriate referral pathways to other care providers and follow-up for visits
- Understand the importance of the care team providing prompt communication with patients regarding their care plans, required care transitions and follow-up care
- Employ evidence-based interactive tools to facilitate the integration of localised care, using existing resources
- Domains of General Practice
D1. Communication skills and the patient-doctor relationship
Ways in which health can be optimised and maintained are communicated to patients, family members and carers
D2. Applied professional knowledge and skills
Continuity of care promotes quality and safety
D3. Population health and the context of general practice
The health needs of individuals are balanced with the health needs of the community through effective utilisation of resources
D4. Professional and ethical role
Professional knowledge and skills are effectively shared with others
D5. Organisational and legal dimensions
Effective triaging and time management structures are in place to allow timely provision of care
- Adult health
The Department of Health