Primary Care Transformation | WentWest Annual Review

This year, our WentWest Primary Care Transformation and Integration team provided support to 350 general practices in our region. In our annual needs survey, 83% of Practice Managers rated the support received in improving their practice systems as high or very high. Almost half of general practices in our region operate with two to five regular GPs and 37% of GPs operate independently, so our team is constantly adapting the support we provide based on individual practice needs.

Our Quality Improvement program includes team-based approaches, peer review, reflective practice, best practice and data analysis. Our teams collaborate with practices to understand their needs and provide them with the data tools and learning opportunities to improve their capacity and capabilities.

1,577,478 active patients
340 general practices
24 PCMHs
242 pharmacies
64 RACFs

Patient Centred Medical Homes

We have been researching and implementing a Patient Centred Medical Home (PCMH) model of care in  Western Sydney since 2014 and now have 24 PCMH practices in our region.

Patient Centred Medical Home

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2020

2023

What Our PCMH Practices Have Achieved This Year

This past year, our PCMH practices have been hard at work implementing the four foundational building blocks of Bodenheimer’s 10 Building Blocks of High Performing Primary Care. So, what have our PCMH practices been working on?

1. Engaged Leadership
2.  Data-Driven Improvement
3.  Patient Registration
4.  Team-Based Care

Undertook leadership courses
Implemented regular team meetings to discuss the external health  environment and practice priorities
Discussed practice priorities daily to align staff towards a common goal
Improved Registrar training
Improved onboarding processes
Undertook whole-team-training on Coding, Data, Topbar and My Health Record
Empowered registered nurses to train in chronic disease management
Facilitated a staff feedback session and survey
Introduced work-from-home flexibility for all team members
Improved care systems for GP Pharmacist role
Set up team outdoor lunch meetings

Improved data systems that track clinical (e.g. cancer screening and diabetes  management), operational (continuity of care and access) and patient  experience metrics
Appointed a Quality Improvement (QI) champion in the team
Engaged in Cardiology in Community program to improve Cardiovascular  Disease risk data
Utilised Lumos reporting for QI
Engaged the whole team in data reports to drive joint QI efforts
Utilised QI tools, such as PenCAT, TopBar, Cubiko, PROMIS 29, Post-COVID  and mental health questionnaires
Improved the proportion of active diabetic patients with an HbA1c test  recorded on file by 20%
Used the Model for Improvement to identify abnormal variations in data and  trigger active participation in Diabetes management and Renal disease
Recalled patients over 70 years who had not had a Bone Mineral Density test
Used COPD data to increase the number of patients who received an influenza  vaccination from 55% to 78.6%

Registered more patients with Care Monitor for better care planning, patient  engagement, population management, and patient self-management
Utilised Patient Reported Experience Measures
Improved process for New Patient Onboarding
Utilised disease registries
Implemented systems for triage and management of COVID-19 patients
Maintained strong connections to patients by doing home visits
Set up video conferencing, E-Scripts, E-Pathology, and Secure Messaging  for patients

Employed a dedicated Chronic Disease Management Nurse
Worked with a GP Pharmacist
Worked with the Western Sydney Diabetes team
Collaborated with partners across the Healthcare Neighbourhood
Improved team oversight of patient care using Care Monitor
Collaborated as a team, including GPs, pharmacists, and nurses, to complete  care plans, health assessments and home medication review
Worked as a team on the pilot Caring for COVID kids in the Community  program

10 Building Blocks