The Health Care Home Model

Developing new roles

The primary care sector is beginning to deal with a serious shortfall in the number of GP consults. This puts a huge load on
existing GP and nurses, which in turn makes it harder to attract  new doctors and nurses to the sector. By developing new roles, we are able to re-allocate tasks that might otherwise be done by GPs and nursing staff. In this way, we can ensure that patients are receiving care in a timely fashion while freeing up time for clinical staff to do what they’ve been trained for — as well as upskill. It also makes for an efficient business model, ensuring all clinicians are working at the top of their scope.

Physician Associates

A complementary, qualified medical role that adds clinical capacity, efficiently. An increasing number of practices are employing physician associates to supplement the clinical team members, especially when there are GP and nursing recruitment issues. Physician associates typically have spent two years in training at medical school following a health-related profession or degree. They support GPs in patient diagnosis and management, taking of tasks such as test analyses, taking medical histories, performing examinations, and developing management plans. They work under the direct supervision of a doctor and are valuable when it comes to supporting timely unplanned care and chronic disease.

Medical Centre Assistants

Our current practices all value the role of the Medical Centre Assistant and is often cite as enabling some of the biggest change. These are unregistered staff who undergo accredited training to support clinical staff by taking on lower-level nursing and administrative tasks. These roles have no component of diagnosis or clinical judgement but have a large role to play in supporting clinical care allowing nurses especially to spend more time on direct patient care.

Thanks to the Patient Access Centre increasing their capacity, most practices employ Medical Centre Assistants from their existing reception staff.

Medical Centre Assistants can perform roles such as:

Greeting patients as soon as they enter the practice and taking core health measurements, such as blood pressure, height and weight before the doctor or nurse consultation

Play a pivotal role in releasing nurse time and improving patient flow

ECGs and spirometry

Providing smoking brief advice

Urine testing and phlebotomy

Planning and organising records and equipment for the following day’s procedures

Assisting at minor surgery

Preparing and stocking consulting rooms

Changing linen

Ordering stock and clinical supplies

Clinical Pharmacists

These add a much-needed specialist skill set to the primary care team. A clinical pharmacist works with the clinical team to target
patients with complex health and social care needs who are on multiple medications, ensuring that they maintain an optimal
drug regime.

They work to support medicine reviews, compliance and education and are integral to the Year of Care approach for patients with
higher needs.

In addition, they may also:

Consult with patients, either face-to-face or over the phone,

To review medications and answer any questions; these

Review all hospital discharge notes to check that patients have been given the correct medication and dosage

Follow up discharged patients to avoid any potential problems that could lead to re-admission to hospital

Order blood tests and refer patients for a GP consultation if necessary

Bring a depth and breadth of pharmaceutical knowledge and experience to patient care and the clinical team

Nurse Practitioners

We are actively developing the Nurse Practitioner role as a key member of a Health Care Home team. As registered nurses who have specialist training in certain skills and many being prescribers, they complement the skills of the GPs. Not only does this add specialist expertise to the team, it means that patient care can be delivered by the right professional first time. Nurse Practitioners are invaluable in leading the Year of Care programme within a practice, supporting the nursing team in managing patients with more complex needs, expand the nursing expertise, skills and leadership that underpin our proactive care.

Community Health Workers

This is a new role we are introducing to our Health Care Home programme and currently piloting it at Te Awamutu Medical Centre. Critical to supporting health and wellness and improving access and engagement; and focusing on improving the outcomes of individuals with diabetes who have lower levels of engagement in managing their disease the Community Health Worker is a trusted member of, and has a close understanding of the local community served. This trusting relationship enables the Community Health Worker to serve as an advocate and conduit between the practice and patients, supporting behavioural lifestyle changes as part of an overall goal-centred care plan.