Readiness checklist

From Health Care Homes wiki
Jump to: navigation, search

This checklist aims to help you identify areas where changes or improvements may be needed in preparation for Stage One of Health Care Homes. The recommendations include resources and suggested activities your practice may consider to address gaps or to highlight areas in need of action.

If you have any questions or if you would like support completing this readiness checklist, contact your local PHN.

Requirement Recommendations
1. Accreditation & eHealth
1.1 Our practice is currently accredited against the RACGP Standards for General Practice; or will be by March 2018. 4th Edition (or 5th Edition where available). For Stage One of Health Care Homes, practices must be currently accredited; or accredited within 12 months of signing the grant agreement (likely March 2017).

For information about how to become accredited or to register for accreditation, simply contact one of the 2 accrediting bodies:

GPA: 02 6944 4042 or visit

AGPAL: 1300 362 111 or visit:

There are also private organisations which will help you achieve accreditation.

1.2 Our practice and providers currently have access. Or are prepared to gain access, to the Health Professionals Online Services (HPOS) system. HPOS is an online platform for doing business with Medicare. You can register for HPOS at the Department of Human Services website.

Your practice will also need to participate in the eHealth incentive PIP (ePIP) and be able to upload information to the My Health Record system. The ePIP Notebook contains useful information for meeting requirement 5 of the ePIP.

For more support, contact your local PHN.

1.3 We currently participate in, or are prepared to participates in, the Practice Incentives Program (PIP) eHealth Incentive (ePIP).
1.4 We are able to register patients for a My Health Record, or are prepared to do so.
1.5 We currently upload information to our patients’ My Health Record.
1.6 Our practice can maintain sufficient insurances, including public liability insurance, and can ensure all health professionals maintain current professional indemnity cover. Discuss with an insurance broker to make sure you have enough cover for the number of staff and type of care you will be providing under the Health Care Home model.

Check that professional registrations for all clinical staff are up to date and that clinicians are acting within their scope of practice.

2. IT & Computer Capabilities
2.1 We have a robust IT system, including compliant clinical software which:
  • Is enabled with My Health Record
  • Can identify eligible patients with multiple chronic conditions
  • Can collect coded data for quality improvement activities
  • Enables secure electronic communication with both internal and external providers
  • Has a recall and reminder system for ongoing patient review
Contact your clinical software provider to ensure your system:
  • Has a built-in coded diagnosis system and diagnosis search capacity.
  • Has a recall and reminder system.

If you're on the ePIP you will be using My Health Record. For more help with My Health Record, secure messaging, and data analysis, contact your local PHN.

2.2 Our practice can estimate the number of patients who have two or more chronic diseases or complex conditions. Using your clinical software or a data analysis tool (e.g. POLAR GP, Pen CAT, MD Insight) extract the number of active patients with common chronic conditions such as diabetes, heart disease, COPD and chronic kidney disease. Some tools allow you to count the number of patients with more than one condition, but if your software doesn't you can still extract lists and subtotal them using Excel. This video shows you how.

This will give you an idea of the potential number of patients who could be invited to enrol with your practice under the Health Care Homes model.

For more help, contact your local PHN's ehealth team.

3. Team capacity
3.1 At least 2 members of our team will be able to participate in the Health Care Homes training program. Practices taking part in Stage One of Health Care Homes will need to participate in a ‘train the trainer’ program which is expected to require between 3-4 days of face to face time from 2 of your team members (usually a Practice Nurse and a GP).

Ensure that your practice would have enough staff available to cover the temporary absence of the participating team members.

3.2 We have adequate clinical staff capacity (e.g. GPs, Nurses, Allied Health, etc.) with adequate skills to take on new activities to plan and coordinate care for enrolled patients. The Health Care Homes model may mean your practice will be implementing new activities, or shifting activities across practice staff, to ensure enrolled patients receive coordinated and team-based care. This may require a change to the current staffing mix and cost allocations within your practice.

If your practice team is currently working at maximum capacity, you may need to consider reallocating roles or working hours of part-time staff, or consider recruiting additional nurses or medical assistants.

3.3 Our clinical staff have the skills required to develop, implement and regularly review each enrolled patient’s shared care plan It is a good idea to discuss with your clinical team their experience, previous education and level of comfort with evidence-based chronic disease management, care and service coordination, and supporting patients with self-management and lifestyle changes. Skills and experience in these areas can vary greatly, this may be a great opportunity to offer additional training in these areas.

You may find useful the Practice Coaching online resource, which has a free chronic disease care module with information on these topics.

3.4 Our practice can easily demonstrate how we support patients with self-management and to become involved in making decisions about their health
3.5 Our practice ensures team members are able to fully utilise their qualifications so they can work to their full scope of practice (e.g. Offering nurse-led clinics for chronic disease management, supporting patients through health coaching, health promotion or lifestyle modification education). The practice management team and lead clinicians such as GPs, should have regular meetings and discussions with other team members (e.g. nurses, medical assistants and allied health). This helps the team understand each other’s scope of practice, and how to use new skills from CPD workshops, conferences or other training.

Health Care Homes would greatly benefit from scheduling regular staff meetings and clinical meetings. Where possible, multidisciplinary meetings (in person or via teleconference) allow particular cases to be discussed with external providers such as allied health, pharmacists, or other relevant community services.

Ensure all GPs and practice staff understand, and support, how the Health Care Home model will be implemented in the practice.

During regular team meetings, encourage discussion of challenges and improvements that could be made to improve internal communication and to promote a culture of collaboration and innovation to optimise patient care.

If your practice does not currently have a documented induction program, you can use a template such as the Staff Training Sheets as a starting point.

The Practice Coaching online resource has free modules for these topics.

3.6 Our practice has an established process to plan and implement care using a team-based approach. (e.g. Regular clinical meetings or case conferences).
3.7 Our practice is committed to being involved in the implementation of the Health Care Homes model and to share patient and practice data with patient’s consent.
3.8 Our practice has a documented induction and orientation program to train new staff on practice policies and procedures in line with the aims and objectives of a Health Care Home.
4. Practice Systems & Change
4.1 Our practice has previously implemented a similar program to the Health Care Homes or we are confident we can make practice changes required to develop Health Care Homes capability within the required timeframe (before 1 July 2017). Your practice may have been involved in a program similar to Health Care Homes where patient care is coordinated outside of a fee-for-service model.

Similar programs include: Coordinated Care Trials, the Diabetes Care project, the CarePoint program, other state based integrated care initiatives and the Coordinated Veteran’s Care (CVC) Program (to an extent).

It is also important to have a consistent practice process to approach planning, implementation and evaluation of practice changes.

Examples of this include the use of a Quality Improvement framework, the use of Plan, Do, Study, Act (PDSA) cycles or any other way the practice uses to regularly plan and reflect on changes (e.g. Team meetings).

The Practice Coaching online resource has a free module for quality improvement activities.

4.2 Our practice has an agreed and consistent process to plan, manage and evaluate changes we make in order to operate as a Health Care Home.
5. Communication with patients Recommendations
5.1 Our practice uses a variety of communication channels to inform patients about new services or policies. (e.g. Practice information sheets, practice website, waiting room posters and/or digital display, patient SMS or email campaigns,

targeted mail outs, etc).

Health Care Homes will need to educate and communicate with enrolled patients on a regular basis. Your practice will need to be comfortable with a variety of communication methods to ensure enrolled patients can access relevant information easily and in a timely manner. You may need to consider including information about what Health Care Homes are, and your particular activities or procedures as part of your practice website, practice information sheet and digital waiting room displays among others.
5.2 Our practice can easily provide enrolled patients with better access to care through inhours telephone support, email or video- conferencing. Health Care Home practices are expected to provide enrolled patients with enhanced access to care. This may mean offering these patients the ability to have phone consultations, support via email or video consultation, or even guaranteeing same-day consults with a nurse or GP in the practice.

Contact your local PHN's ehealth team for support with video consultations.

It is also important to provide patients with clear information about what to do if care is needed after-hours. This may include the use of ‘symptom action plans’, which outline steps for self management as well as what to do if their condition escalates (e.g. after hours support by the practice, locum service or emergency assistance).

5.3 Our practice can easily ensure that all enrolled patients are aware of what to do if they require access to after-hours care.
6. Practice Facilities
6.1 We have adequate physical space in our facility to provide patients with a comfortable and confidential environment for consultation with GPs and other members of the team (e.g. Nurse consultations or for provision of group health coaching sessions). The practice may need to consider allocating consulting rooms for new activities and team members involved in the care of enrolled patients. Some practice with limited physical space may consider using or leasing consulting or meeting areas from nearby facilities, for example, for group coaching activities.

For example: a practice may consider using space at a nearby allied health clinic, or even partnering with a local pharmacy or community service with an appropriate meeting space, to provide enrolled patients with group health coaching.

7. Funding Arrangements
7.1 Our practice has agreed on how Health Care Home funding ($10,000 grant and enrolled patient funding) will be used and distributed within the practice and how GPs will be remunerated for leading or providing care to enrolled patients in the absence of Medicare items. Every Health Care Home will need to internally discuss and decide how funds for this initiative will be used and how team members, especially GPs, will be remunerated in the absence of fee-forservice Medicare items.

The practice will need to plan and estimate the cost of up-skilling, recruiting new staff, or expanding hours of existing staff to ensure adequate capacity to function as a Health Care Home. There will likely be additional administrative costs incurred during the setup phase of the initiative.

GP remuneration is a delicate area where discussion and team consensus will need to be reached between practice owners, GP partners and sub-contractor or employed GPs.

Since GPs will not be able to claim MBS items for encounters related to the patient’s chronic conditions, an internal agreement will be required to ensure individual GPs are adequately remunerated for care provided, but also that the increasing demand on other team members, such as nurses or medical assistants, is also recognised.