Cohort Profile: Effectiveness of a 12-Month Patient-Centred Medical Home Model Versus Standard Care for Chronic Disease Management among Primary Care Patients in Sydney, Australia

Abstract

Evidence suggests that patient-centred medical home (PCMH) is more effective than standard general practitioner care in improving patient outcomes in primary care. This paper reports on the design, early implementation experiences, and early findings of the 12-month PCMH model called ‘WellNet’ delivered across six primary care practices in Sydney, Australia. The WellNet study sample comprises 589 consented participants in the intervention group receiving enhanced primary care in the form of patient-tailored chronic disease management plan, improved self-management support, and regular monitoring by general practitioners (GPs) and trained clinical coordinators. The comparison group consisted of 7750 patients who were matched based on age, gender, type and number of chronic diseases who received standard GP care. Data collected include sociodemographic characteristics, clinical measures, and self-reported health assessments at baseline and 12 months. Early study findings show the mean age of the study participants was 70 years with nearly even gender distribution of males (49.7%) and females (50.3%). The most prevalent chronic diseases in descending order were circulatory system disorders (69.8%), diabetes (47.4%), musculoskeletal disorders (43.5%), respiratory diseases (28.7%), mental illness (18.8%), and cancer (13.6%). To our knowledge, the WellNet study is the first study in Australia to generate evidence on the feasibility of design, recruitment, and implementation of a comprehensive PCMH model. Lessons learned from WellNet study may inform other medical home models in Australian primary care settings.

Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia.

“…Of the ve dimensions of EQ-5D, WellNet patients reported substantial improvement particularly on two domains of pain/discomfort and usual activities in terms of a 33% and 28% increase, respectively, in the 'no problem' level at follow-up. This could be attributed to the primary objective of the WellNet program in improving self-management behaviour among patients to effectively manage symptoms associated with their chronic conditions [27]. Improved selfmanagement behaviours are strongly associated with improved HRQoL [48,49].…”

“…Patients living in nursing homes and those with severe cognitive impairment or terminal illness (n=10) were excluded. More details on the risk algorithm, enrolment, and data collection are reported elsewhere [27]. Of the 636 consenting participants, 616 who completed the EuroQol ve dimensions and ve levels version (EQ-5D-5L) questionnaire at baseline were analysed in this study.…”

“…enabling access and reminders to the next scheduled GP appointments and prescriptions. Further details on how CCs monitored usage of GoShare and MediTracker are reported elsewhere [27].…”

Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: A before-and-after study.

“…WellNet program and study design Sonic Clinical Services (SCS) designed a 12-month chronic disease management (CDM) program called 'WellNet' which aims to provide a GP-led, MDT based care for patients with one or more chronic conditions. This enhanced primary care program is built upon the principles of the PCMH model and is guided by other evidence based, best practice models of clinical care in order to deliver high quality patient-centric care that is con gured to individual risk and complexity levels [30].…”

“…The 12-month WellNet program is designed to integrate GPs with specially trained chronic disease management (CDM) Care Coordinators (CC) within each of the six participating GP practices [30]. On entry to the program, the team of GPs and CCs coordinate with patients to undertake a range of validated general and disease-speci c risk assessments to determine patient's baseline health status and wellbeing.…”