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Home Medical Home Community Hospital Teams

Home Medical Home Community Hospital Teams

Home Medical Home Community Hospital Integrated Care Teams - Each person and their carers

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

LHD PRIMARY HEALTH NETWORK Home Medical Home Community Hospital The Medical Neighbourhood Everyone has

LHD PRIMARY HEALTH NETWORK Home Medical Home Community Hospital The Medical Neighbourhood Everyone has three has two Jobs

Home Medical Home Neighbourhood Hospital

Home Medical Home Neighbourhood Hospital

What is a Patient Centred Medical Home?

What is a Patient Centred Medical Home?

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Clinician Experience • Over the last 3 months, I was notified, as much as

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

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.