Primary Care Home

Strengthening and redesigning primary care Staff come together as a complete care community – drawn from GP surgeries, community, mental health and acute trusts, social care and the voluntary sector –  to focus on local population needs and provide care closer to patients’ homes. 

Four key characteristics of Primary Care Home an integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care; a combined focus on personalisation of care with improvements in population health outcomes; aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards and  provision of care to a defined, registered population of between 30,000 and 50,000

Hospital GP Pharmacy Mental Health Community Health Community* Commissioners Community Health Pharmacy

High Intensity:Frail Elderly- Virtual Ward, Care Homes, Grand Ward Round High Intensity:Frequent attenders - Liaison Psychiatry for medical unexplained symptoms High and Rising Need: Profile and Prevalence, Expert Patient, Carer identification and support Low Need / Stable: Mental Health awareness, Community Pharmacy integration - annual reviews, Diabetes pathway review, social prescribing, secondary care audit, Community dermatology / MSK services, online support (web / care plans) General Health Maintenance: Collaborative flu campaign, patient education, schools health literacy, Women's Health clinical audit, HIPSTER Pre-diabetes, Veterans Support, nursing capacity review General Health Access: Urgent Care Team, Online consultation, Online self care advice, Capacity Modelling, Near Patient Testing