1. Teams
Home
Medical Home
Community
Hospital

2. Home
Medical Home
Community
Hospital
Integrated Care Teams
Each person and their carers can partner with the team they need to manage their health
This team is joined up
While the team gets larger and smaller depending on the person’s needs, the core team is constant
People are not ‘transferred’ from team to team

3. The Medical Neighbourhood
PRIMARY HEALTH NETWORK
LHD
Home
Medical Home
Community
Hospital
The Medical Neighbourhood
Everyone has two Jobs
Everyone has three Jobs

4. Home
Medical Home
Neighbourhood
Hospital

5. What is a Patient Centred Medical Home?

11. Clinician Experience
Over the last 3 months, I was notified, as much as I wanted to be, when my high risk chronic disease patients were admitted to hospital?
Over the last 3 months, I was involved, as much as I wanted to be, in decisions about the care and treatment of my high risk chronic disease patients when they were admitted to hospital?
Over the last 3 months, I felt confident that my high risk chronic disease patients were regularly checked on or appropriately monitored to reduce risk of hospital admission
Over the past 3 months collaboration between State Health Chronic Disease Nursing and General Practice has been working well.

12. Examples of PRM measures
Over the past 3 months, it has been easy for me to get appointments to see my GP or nurse when I needed to?
Over the past 3 months, it has been easy for me to manage my health
I am confident I know about how to help prevent further problems with my health condition
I feel I have a good understanding of what each of my prescribed medications are for.
Being active role in my own care is the most important thing for my health.