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Home Medical Home Community Hospital Teams

Home Medical Home Community Hospital Integrated Care Teams - Each person and their carers can partner with the team they need to manage their health - This team is joined up - While the team gets larger and smaller depending on the person’s needs, the core team is constant - People are not ‘transferred’ from team to team

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Home Medical Home Neighbourhood Hospital

What is a Patient Centred Medical Home?

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Clinician Experience • Over the last 3 months, I was notified, as much as I wanted to be, when my high risk chronic disease patients were admitted to hospital? • Over the last 3 months, I was involved, as much as I wanted to be, in decisions about the care and treatment of my high risk chronic disease patients when they were admitted to hospital? • Over the last 3 months, I felt confident that my high risk chronic disease patients were regularly checked on or appropriately monitored to reduce risk of hospital admission • Over the past 3 months collaboration between State Health Chronic Disease Nursing and General Practice has been working well.

Examples of PRM measures • Over the past 3 months, it has been easy for me to get appointments to see my GP or nurse when I needed to? • Over the past 3 months, it has been easy for me to manage my health • I am confident I know about how to help prevent further problems with my health condition • I feel I have a good understanding of what each of my prescribed medications are for. • Being active role in my own care is the most important thing for my health.