Australian general practice: primed for the “patient-centred medical home”?

The central role for Australian general practice in providing high-quality affordable health care for all Australians has been underlined repeatedly by national health bodies including the National Health and Hospitals Reform Commission (NHHRC), the Council of Australian Governments Reform Council, the National Primary Health Care Strategy, the National E-Health Transition Authority and Health Workforce Australia. The Australian Health Practitioner Regulation Agency has recognised general practice as a specialty in its own right.1 The Royal Australian College of General Practitioners has defined general practice as

Many of the steps to enable this are in train. The RACGP has about 26 000 members undertaking ongoing quality improvement and continuing professional development; 80% of general practices are fully accredited and 96% of GPs are using a computer for clinical care. The general practice registrar intake has doubled since 2005, refreshing a stretched and depleted workforce. Innovative practice models have greatly expanded general practice teams and service scope.3 Both the personally controlled electronic health record, which will require Australia’s GPs to be its creators and custodians, and the establishment of Medicare Locals further cement general practice’s central role in health care reform.

There remain, however, major challenges to be overcome in Australia in relation to workforce distribution; the quality and consistency of available care; rewarding appropriate prevention; chronic disease management; integration with other sectors; and a “whole health system” focus. In the United States, the patient-centred medical home (PCMH) is showing promise in tackling many of these challenges.

The PCMH initiative was launched in 2007 by a number of colleges and academies in the US and describes a primary care model aimed at better meeting the needs of contemporary communities.4

There are four key elements of the model — practice organisation, health information technology, quality measures and patient experience.5 Intended outcomes of the model include:

• an ongoing patient relationship with a personal physician who takes overall responsibility for patient care and leads a team of individuals, who also provide care for the patient

• coordination and integration of care across all elements of the complex health care community, enabled by patient registration, information technology, and health information exchange

• practice of evidence-based medicine and use of clinical decision-support tools to guide decision making and support quality and safety

• physician accountability and voluntary engagement in performance measurement and quality improvement, expanded hours to enhance access to care, e-access and payment reform.6

Adoption of the PCMH in the US has resulted in improved quality measures, performance and service use, with a highly significant reduction in avoidable hospital admissions, emergency department use and overall care costs.7-10 A report based on an analysis of 31 studies of this care model was recently released by the US Agency for Healthcare Research and Quality. The report concluded that, while the model was promising in relation to improving the experiences of patients and care processes, further evidence was required to make a firm determination regarding its effects on clinical and economic outcomes.11

Interest in the core principles of the PCMH in Australia is not new. The NHHRC identified linkage to a “health care home” as a critical reform initiative in improving care continuity and coordination.12 The vision for general practice recently articulated by the RACGP overlaps markedly with key elements of the PCMH. A quality general practice of the future describes similar approaches to patient centricity, continuity of care, appropriate care settings, delegated authority, growth in e-health opportunities and service access, and accountability for preventive health and long-term patient care and support via voluntary patient linkage to the practice.13 Recent New South Wales data evaluating the impact of such linkage on care quality and use of acute services support this view.14

To trial, and potentially implement, the PCMH in Australia, attention needs to be focused on the missing pieces — incentives to facilitate formal patient–practice linkage; care delivery and outcomes as well as planning; expanding existing practice quality and safety tools and incentives; practice systems to support continuity of care; reward for e-consulting; and integration of care with the “medical neighbourhood”, including the new Medicare Locals and Local Hospital Networks.

Australian general practice has an impressive track record by international standards — with modest cost and high population access. It now has a clear vision, good international data on which to base its patient care initiatives, a ready and well trained workforce, and a central position in our health care reform agenda. Will ongoing primary care reform by state and federal governments progress appropriate recognition, reward and support for the critical elements in our health care evolution? If yes, we are ready for exciting times indeed.