1. Primary Care Home 1st / 2nd November 2017
Andy Mullins, Dr Steve Laitner

2. PCH has four key characteristics1
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. 2 3 4 2
© 2017 National Association of Primary Care

3. NAPC’s definition of primary care
A person’s first point of contact with the health and social care system​
Provides the majority of our preventative and curative health needs, health promotion and care monitoring requirements
A person-centred (holistic) approach, rather than disease focused, to continuous lifetime care ​
A comprehensive set of services, delivered by multi-professional teams, with a focus on population health needs​
The co-ordination and integration of care in partnership with patients and providers​

4. NAPC Definition of Population health management
Population health management is a proactive approach to managing the health and well-being of a population. It aims to incorporate the total care needs, costs and outcomes of the population. It involves segmenting the population into groups of people with similar characteristics to enable targeted interventions for both those population cohorts and the individual citizens within.

5. Lots of models
Disease / service focused Risk focused Holistic needs focused

6. Generally well/ good wellbeing Long term condition(s)/ social needs
Complexity of LTC(s)/ social need and/or with disability
Children and young people
Working age adults
Older people
Based around different response needed, whether integrated team needed or not

7. Population health cube
Ongoing Care Needs
Elective Care Needs
Urgent Care Needs
Children and
Young People
Working Age Adults
Older People
Complex Needs
Long Term Condition(s) /
long term needs
Generally Well
© 2017 National Association of Primary Care

8. 8 Acute Team Continuous Care Team Multi-Agency Team Dementia
Acute Care
Generally well
Long term conditions
Complexity of LTC(s)
and/or disability
Low risk
High risk
Children and Young People
Neonates
Infants
Toddlers
Children
Adolescents
Working Age Adults
Young
Middle aged
Older working age
Older People
65-80
80-90
90+
Acute Team
Nurse Practitioner
Paramedic GP
Continuous Care Team GP
Pharmacist
Multi-Agency
Team
Specialist
Case
Management
Dementia 8

9. Less about what, more about how…
Communities are living longer with increasingly complex needs, the people in our surgeries are also have social needs, on top of this we have a workforce crisis. So the traditional model – more of the same – isn’t the solution.
This requires a mindset change...thinking differently
“Broader attention to wellbeing, prevention and treatment”
“Recognition that we can’t and don’t have to do this all ourselves”
“It is a journey of empowerment, exploration and innovation”
“Focus on relationships through collaboration and partnerships”
“Really understanding population needs (not just health)”
“Getting to know and using the assets of the whole community”

10. Spread of primary care home
Spread: More than 200 sites​ ​
Population: 8 million
covering 14% of the population​
GP: 828 GP practices / 11%​
STP coverage: 34 ​
ACS coverage: 5 
Spread has been incredible – some are maturing nicely, others have only just started. Mix of rural, urban
No one PCH looks the same but they are all working towards the 4 characteristics
Lets take a couple of examples……
St Austell
The challenge High levels of long-term unemployment, socio-economic deprivation, and high prevalence of chronic disease and obesity.
What they did
Social Prescribing Facilitator refers patients to resources ranging from walking groups, Zumba and pilates classes, to canoe clubs the to increase physical activity and improve nutrition and reduce isolation. Connections made with 150 organisations across the community.
The impact First cohort of 150 patients - mostly diabetic or pre-diabetic.
Of the 52 to have completed the 12 weeks programme so far, 94% saw an increase in their wellbeing score, 62% had lost weight and 8% had stayed the same. The Social Prescribing Facilitator is now holding three clinics a week an enrolling 15 new patients a week
Larwood and Bawtry
The challenge PCH covers several villages in Nottinghamshire and South Yorkshire, some with high levels of deprivation and disease. Two practices wanted to rebuild the primary care team and work in partnership with other organisations to improve services and remain sustainable.
What they did Two GP surgeries created integrated teams co-locating community and voluntary services in the practices. Community advisors work from practices, running citizens advice clinics signposting patients to voluntary and non-medical services locally. Close work with district council to support people with housing needs, social care clinics are held on site, a practice pharmacist appointed to advise and carry out medication reviews in care homes.
The impact 5% reduction in prescribing costs (over 7 months) and projected £229,000 annual savings following the practice pharmacist appointment. Emergency admissions dropped by 8% over the same period.

11. Tips on getting started from mature Primary Care Homes
“Get to know your partners and their capabilities”
“Make some headspace”
“Go where the energy is”
“Create a shared vision” (Start small)
“Don’t worry about organisation form”
“Learn to let go”
“Explore the data and segment your population needs”
“Fail quickly and learn”
“Assume you have permission”

12. Typical Journey – and support available
Engagement
Understand Population Health Data and Needs
Care Model Development
Workforce, training, education, culture and planning
Alignment of resources and financial drivers
Evidence and evaluation 1 2 3 4 5 6
Development Cycle
Engage all organisations and inspire and empower the workforce in the journey 
Using data to understand the preventative, ongoing and urgent care needs to improve health and wellbeing Designing the appropriate care models to address these needs
Develop the multidisciplinary teams needed, focused on collaboration across organisations, not competition 
Identify and monitor the outcomes that matter to local populations
Building the energy, commitment and capability
National Network
Care Model Examples
National and international Lessons 12

13. PCHs have released benefits for patients, staff, practices and the wider system
A&E Attendances q
£27k of savings each year enabled by providing extended access in Thanet
A&E Admissions
£295k of savings from reductions in A&E admission driven by Thanet Health
GP Referrals
330 GP referrals to hospital avoided demonstrated by Beacon
Prescribing Costs
£220k of prescribing savings demonstrated by Larwood and Bawtry
Staff Satisfaction p
67% of staff surveyed felt that PCH had improved their job satisfaction
Utilisation
78% of staff felt PCH had decreased or not added to their workload
Staff Retention
86% of staff regarded Beacon Medical Group as a good employer
Patient Experience
82% of staff felt that PCH had improved patient experience
GP Waiting Time
6 day reduction in the average time patients wait to see their GP
Population Health
13% increase in flu vaccinations for patients with COPD registered with Beacon
Length of Stay
8 day reduction for admitted care home residents registered with Beacon
Over the last month we commissioned a small piece of work to look at 3 of the PCHs and understand the impact they have been able to make on patient care, staff satisfaction, and wider system priorities including the triple aim
NAPC, PA Consulting (2017) Does the primary care home make a difference?

14. Doing Things Differently (1)
Liaison Psychiatrist based in practice
Acute response team for elderly and frail
In house
pharmacist
Integrated teams focused on patients most likely to be admitted to hospital
Co-located Community Service Teams in Practices - creating integrated nursing teams
Developing the Team 2
Reducing Emergency Admissions 1
Clinical nurse manager co-ordinating nursing
Training and support for workers in Care Homes
Virtual Ward, Care Home ‘Ward Rounds’
Frailty pathway/clinics, Home visit team,
Urgent Care Teams - Advanced Paramedic/Nurse Practitioner urgent care clinics
Wounds dressing clinic in social setting
Chronic Pain Mindfulness Courses
The great news is that much of what we see emerging from PCHs are familiar - just delivered in a much more joined up way and in partnership across communities.
Physical AND Mental Health 3
Improving Access 4
Hospital clinics in the community
Counselling Services (young people)
Veterans Service
Telephone system and telephone triage 14
© 2017 National Association of Primary Care

15. Doing Things Differently (2)
Sharing IT, Back Office Functions
New Popup lung health checks
Stronger voice for Primary Care at system level 6
Patient Activation Measures and support for lifestyle changes
Scaling up Primary Care
Type 2 diabetes specialist service
Supported Self Care/ Long Term Conditions 5
Joining up on developing new relationships across the community
Heart Failure Clinics in Community
Self monitoring telehealth systems
Social Prescribing – working closely with 3rd Sector and employers
Food Bank
Fire Service Falls Programme
Training Pharmacy Assistants to help signpost and navigate
Discharge Support
Signposting, Care Navigation and Social Prescribing 8
Integrated Partnership Working 7
Focus on dementia, elderly and frail
Integrated district and community nursing teams
Coffee Morning Clubs, Walking Clubs
Health, Social Care, Co-ordinators – non-clinical support, benefits advice
Dressing clinics in libraries and town halls
1515
© 2017 National Association of Primary Care

16. Tools to help sites learn and develop
1) Learn about PCH model 2) Help you identify the support you need to implement the model 3) Guide you through the development process for each of your PCH initiatives 4) Enable you to generate an action plan to share with your PCH colleagues 5) Help your site to assess progress in developing the PCH model and measure its impact on population health outcomes
Tools to help sites learn and develop 1
Learn about the PCH model 2
Design your first PCH initiative 3
Action plan with your colleagues 4
Support you in developing the model 5
Evaluate the impact on your population

17. Aligned aims
Five Year Forward View: Improving the health and wellbeing of the population Improving the individual outcomes & experience of care Reducing the per capita cost of care
Accountable Care System:
New model of Primary Care
Improved population health
Better use of health system resources 1 1 2 2 3 3 17

18. Improving the experience of providing care
Aligned aims
Five Year Forward View: Improving the health and wellbeing of the population Improving the individual outcomes & experience of care Reducing the per capita cost of care
Accountable Care System:
New model of Primary Care
Improved population health
Better use of health system resources 1 1 2 2 3 3
Improving the experience of providing care
Sikka et al (2015)BMJ Quality and Safety 18

19. Discussion 19