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Improving health and wellbeing through person-centred care
Our experience Sydney North Health Network
Person-centred care may well be the future of general practice in Australia—and it’s here now in Sydney’s north. A person-centred care model, sometimes referred to as a person-centred medical home (PCMH), combines the traditional core values of a family-focused medical practice with a team-based approach to care and an ongoing, active relationship between the person and their healthcare team.
‘Person-centred care focuses on the patient, their needs, and their goals to achieve better health outcomes. It is a team-based approach to healthcare, where the GP works with a team to look after a patient’s welfare and health. This allows health professionals to focus on their individual skill sets to deliver a better quality of care to patients,’ says Sydney local northside GP, Dr Kiril Siebert.
Sydney North Health Network (SNHN) provides support and education to healthcare teams to help enhance patient experience of coordinated care, improve systems and data collection, optimise health and wellbeing, and improve the work life of healthcare clinicians.
‘This shared or team approach not only provides additional value for patients, it can help prevent burnout of our medical professionals’, says Sue Barry, Primary Care Coordinator/Program Lead at SNHN.
Practice nurse Kathleen Chapman said she was in a very fortunate position in that she was able to spend time with the patient. ‘We work out what they need and what is important to them. I get to do a full health assessment which can take up to an hour depending on complexity, then we go and talk to the GP together. We like to make sure they keep the same doctor and nurse, and work towards their healthcare goals as a team.
SUE BARRY Primary Care Coordinator/ Program Lead, SNHN
KATHLEEN CHAPMAN Practice Nurse
It’s about connecting with and continually following up with the patient. We also connect them to services around the local community to help them in getting well and staying healthy.’
Local GP Dr Mehrnoosh Alian emphasised the ongoing and preventative approach to care. ‘You don’t have to be sick in order to seek and receive care. It can all be a part of your preventative healthcare program. When a person is involved in their own care, they have a better understanding of their own needs,’ says Dr Alian.
Dietitian Lisa Mesiti said that through the PCMH model, patients who were previously isolated in the community ‘now have a place to come and build health-based relationships with our healthcare team and other patients. This is really rewarding. Whether they are struggling with several chronic conditions at once or are reasonably healthy, we regularly check in with patients to help them stay on track in achieving their health goals.’ >
DR MEHRNOOSH ALIAN Local GP
LISA MESITI Dietitian
PCMH IN ACTION
Northern beaches patient Meg Parsons has Chronic Obstructive Pulmonary Disease (COPD) Her condition was progressively getting worse and her quality of life was deteriorating.
The moment Meg stepped into a north Sydney Person-Centred Medical Home (PCMH) practice, the receptionist recognised her distress, enabling Meg to be promptly seen by the practice nurse and GP.
Meg was adamant she did not want to go to a hospital emergency department. The practice team listened to her concerns and undertook an immediate course of treatment. They placed Meg on oxygen, which her greatly improved her breathing and alleviated her distress.
The practice nurse, Kath Chapman, became Meg’s primary contact. Kath referred Meg to the best health services able to assist her in better managing her condition. Local GP Dr Mehrnoosh Alian now provides a compassionate, ongoing and preventative approach to Meg’s care.
The PCMH team empowered Meg to be at the centre of her own care and encouraged her to take proactive steps to manage her condition.
Meg was referred to a local hospital to undertake exercise rehabilitation and sent to a specialist physiotherapist who focused on her breathing techniques.
The team also arranged for an aged care assessment, which provided Meg with a home cleaning service. Her home was regularly cleared of dust, and she could breathe more easily. Meg was now able to focus on her exercise regime and, using a pedometer, she could track her steps and improve her fitness.
‘I was blown away with how the person-centred care practice helped me. Suddenly my whole world and health improved. I had choices, I was connected to the services I needed. They make you feel very important and worthwhile’, she said.
PERSON-CENTRED MEDICAL HOMES IN THE US
Dr Kiril Siebert recently undertook a study tour of general medical practices in the USA that were using the PCMH model of care. He says general practice teams in the American healthcare system are generally much bigger than those in Australia.
Sydney northside GP Dr Kiril Siebert
‘In the US practice system there are often doctors, nurses, behavioural therapists, pharmacists, medical assistants and care coordinators all in the one practice.
‘I also noticed that the practices in America rely heavily on their data as benchmarks to improve standards, and to proactively improve quality of care. American practices are also not shy to share their data within practices or beyond. They were very upfront and proud about sharing their de-identified data which I think is great and something we could do better here in Australia.’
Dr Siebert was also impressed by one practice that had a ‘Patient and Family Advisory Committee’ (PFAC). The PFAC was a committee of 10 patients with whom the practice consults on health campaigns and potential practice improvements.
‘Members of the committee were really enthusiastic
and empowered about the part they played in their own healthcare. I would love to introduce PFACs here in
Australia’, Dr Siebert said.
